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Evolving Gallstone Ileus SUNY – Downstate Case Conference January 12, 2012 www.downstatesurgery.org

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Page 1: Evolving Gallstone Ileus - SUNY Downstate Medical Center · Evolving Gallstone Ileus SUNY – Downstate Case Conference . January 12, 2012

Evolving Gallstone Ileus

SUNY – Downstate

Case Conference

January 12, 2012

www.downstatesurgery.org

Page 2: Evolving Gallstone Ileus - SUNY Downstate Medical Center · Evolving Gallstone Ileus SUNY – Downstate Case Conference . January 12, 2012

Initial Presentation

• HPI: 90 yo F c 1wk h/o abdominal pain and N/V. Denied F/C. Passing flatus/BM.

• PMH: DM, HTN, CAD.

• PSH: C-sections x 3.

• Meds: Enalapril, HCTZ, Plavix, Colace

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Page 3: Evolving Gallstone Ileus - SUNY Downstate Medical Center · Evolving Gallstone Ileus SUNY – Downstate Case Conference . January 12, 2012

Exam

• VS: 97.2 54 197/76 17 99%RA

• WDWD, NAD

• RRR

• CTAB

• Soft, mildly distended, nontender.

• Well healed Pfannenstiel scar.

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Page 4: Evolving Gallstone Ileus - SUNY Downstate Medical Center · Evolving Gallstone Ileus SUNY – Downstate Case Conference . January 12, 2012

Labs

• CBC 4.9 / 10 / 32 / 290

• BMP 139 / 3.5 / 103 / 24 / 11 / 0.83 / 198

• Amy 37 / Lip 5

• AST 21 / ALT 16 / TB 0.5

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Hospital Course

• Admitted for observation.

• Negative MRCP.

• Symptoms resolved.

• Discharged to home on regular diet.

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Page 8: Evolving Gallstone Ileus - SUNY Downstate Medical Center · Evolving Gallstone Ileus SUNY – Downstate Case Conference . January 12, 2012

Second Presentation

• Returned to ED 3 days post d/c, with recurrence of symptoms.

• Exam unchanged.

• Labs – CBC 6.3 / 12 / 38 / 271

– BMP 137 / 5.4 / 100 / 26 / 14 / 0.78 / 122

– Amy 53 / Lip 15

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Hospital Course

• Readmitted for observation.

• Symptoms resolved; tolerated diet.

• At 1 week, abrupt ab distention, N/V.

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Page 14: Evolving Gallstone Ileus - SUNY Downstate Medical Center · Evolving Gallstone Ileus SUNY – Downstate Case Conference . January 12, 2012

Operative Intervention

• Underwent uneventful enterolithotomy.

• Remaining bowel unremarkable.

• Dense adhesions in the RUQ.

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Page 16: Evolving Gallstone Ileus - SUNY Downstate Medical Center · Evolving Gallstone Ileus SUNY – Downstate Case Conference . January 12, 2012

Hospital Course

• Started diet POD 7.

• Postop course complicated by refractory afib/flutter.

• Discharged to rehab facility POD 22.

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Page 17: Evolving Gallstone Ileus - SUNY Downstate Medical Center · Evolving Gallstone Ileus SUNY – Downstate Case Conference . January 12, 2012

Questions

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Page 18: Evolving Gallstone Ileus - SUNY Downstate Medical Center · Evolving Gallstone Ileus SUNY – Downstate Case Conference . January 12, 2012

Gallstone Ileus

• Mechanical obstruction caused by intraluminal impaction of one or more gallstones anywhere between the stomach and the rectum.

• S/Sx frequently nonspecific.

• Elderly patient with comorbid conditions.

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Page 19: Evolving Gallstone Ileus - SUNY Downstate Medical Center · Evolving Gallstone Ileus SUNY – Downstate Case Conference . January 12, 2012

Epidemiology

• 1-4% of all cases of intestinal obstruction in general population.

• 25% of nonstrangulated SBO over age of 65.

• Mean age 65 to 75.

• Accurate preop diagnosis in 24 to 73% of cases.

Reisner RM, et al. Am Surg. 1994;60(6):441-446.

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Page 20: Evolving Gallstone Ileus - SUNY Downstate Medical Center · Evolving Gallstone Ileus SUNY – Downstate Case Conference . January 12, 2012

Pathogenesis

• 60-80% have demonstrable bilioenteric fistula. – 60% cholecystoduodenal fistulas

• 20-30% have complex RUQ mass on laparotomy.

• Fistulas can occur between the biliary tree and stomach, small bowel, large bowel.

• Bilioenteric fistulas may be associated with surgery, gall bladder carcinoma, duodenal ulcers, and IBD.

van Hillo M, et al. Surgery. 1987;101(3):273-276.

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Page 21: Evolving Gallstone Ileus - SUNY Downstate Medical Center · Evolving Gallstone Ileus SUNY – Downstate Case Conference . January 12, 2012

Related Eponyms

• Mirizzi Syndrome

• Bouveret Syndrome

• Rigler’s Triad

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Page 22: Evolving Gallstone Ileus - SUNY Downstate Medical Center · Evolving Gallstone Ileus SUNY – Downstate Case Conference . January 12, 2012

Related Eponyms

• Mirizzi Syndrome – Common hepatic duct or CBC obstruction caused

by compression from GS in cystic duct or Hartmann’s pouch

• Bouveret Syndrome – Gastric outlet obstruction caused by GS impaction

in distal stomach or duodenum

• Rigler’s Triad – Bowel obstruction, pneumobilia, ectompic

gallstone.

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Page 23: Evolving Gallstone Ileus - SUNY Downstate Medical Center · Evolving Gallstone Ileus SUNY – Downstate Case Conference . January 12, 2012

Anatomy

• Stones may pass spontaneously through Ampulla of Vater.

• 90% of obstructing GS > 2cm in diameter. • Impaction occurs in:

– Ileum 60.5% – Jejunum 16.5% – Stomach 14.2% – Colon 4.1% – Duodenum 3.5%

Clavien PA, et al. Br J Surg. 1990;77(7):737-742.

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Page 24: Evolving Gallstone Ileus - SUNY Downstate Medical Center · Evolving Gallstone Ileus SUNY – Downstate Case Conference . January 12, 2012

Presentation

• Abdominal pain, distention, and vomiting.

• Obstruction 50-70%. Frequently, intermittent. “Tumbling obstruction.”

• Previous hx of gallstone disease did not contribute to diagnosis.

van Hillo M, et al. Surgery. 1987;101(3):273-276.

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Signs and Symptoms www.downstatesurgery.org

Page 26: Evolving Gallstone Ileus - SUNY Downstate Medical Center · Evolving Gallstone Ileus SUNY – Downstate Case Conference . January 12, 2012

Radiographic Findings

• Air/contrast in biliary tree.

• Visualization of stone in the intestine.

• Change in position of previously identified stone.

• Partial or complete obstruction.

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Page 27: Evolving Gallstone Ileus - SUNY Downstate Medical Center · Evolving Gallstone Ileus SUNY – Downstate Case Conference . January 12, 2012

Other Studies

• Plain X-ray – May demonstrate pneumobilia, enterolith.

• US – May be useful in identifying fistula or enterolith

movement during bowel peristalsis.

• Endoscopy – May directly identify fistula.

Lasson A, et al. Eur J Surg. 1995;161(4):259-263. Lassandro F, et al. AJR Am J Roentgenol. 2005;185(5):1159-1165.

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AXR www.downstatesurgery.org

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CT www.downstatesurgery.org

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AXR www.downstatesurgery.org

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CT www.downstatesurgery.org

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Endoscopy www.downstatesurgery.org

Page 33: Evolving Gallstone Ileus - SUNY Downstate Medical Center · Evolving Gallstone Ileus SUNY – Downstate Case Conference . January 12, 2012

Treatment

• Surgery – enterolithotomy (open vs laparoscopic).

• Inspection of entire bowel (small and large). – Multiple stones have been reported in 3-40% of

Pts.

• Extracorporeal shockwave lithotripsy successfully employed.

Ravikumar R, et al. Ann R Coll Surg Engl. 2010;92(4):279-281.

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Page 34: Evolving Gallstone Ileus - SUNY Downstate Medical Center · Evolving Gallstone Ileus SUNY – Downstate Case Conference . January 12, 2012

Cholecystenteric Fistula

• 1 Stage – enterolithotomy, cholecystectomy, fistula repair.

• 2 Stage – enterolithotomy.

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Page 35: Evolving Gallstone Ileus - SUNY Downstate Medical Center · Evolving Gallstone Ileus SUNY – Downstate Case Conference . January 12, 2012

1 Stage

• Prevents recurrence. – Up to 17% have recurrent GSI.

– Prevents cholecystitis, cholangitis.

• GB Ca higher in Pts with cholecystenteric fistula.

Clavien PA, et al. Br J Surg. 1990;77(7):737-742. Redaelli CA, et al. Surgery. 1997;121(1):58-63.

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Page 36: Evolving Gallstone Ileus - SUNY Downstate Medical Center · Evolving Gallstone Ileus SUNY – Downstate Case Conference . January 12, 2012

2 Stage

• Most consider enterolithotomy sufficient. – Pt population high risk.

– Recurrence low – less than 5%

– Reoperation rate less than 10%

• Increased morbidity and mortality.

Doko M, et al. World Journal of Surgery. 2003;27(4):400-404. Reisner RM, et al. Am Surg. 1994;60(6):441-446. Tan Y, et al. Singapore Med J. 2004;45(2):69–72.

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Page 37: Evolving Gallstone Ileus - SUNY Downstate Medical Center · Evolving Gallstone Ileus SUNY – Downstate Case Conference . January 12, 2012

Take-Aways

• GSI may be the source of unusual presentations of pneumobilia, SBO, or abdominal pain.

• For the typical GSI Pt, enterolithotomy is sufficient.

• Inspect entire small bowel for multiple GS.

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Page 38: Evolving Gallstone Ileus - SUNY Downstate Medical Center · Evolving Gallstone Ileus SUNY – Downstate Case Conference . January 12, 2012

References 1. Ravikumar R, Williams JG. The operative management of gallstone ileus. Ann R Coll Surg Engl. 2010;92(4):279-281.

2. Reisner RM, Cohen JR. Gallstone ileus: a review of 1001 reported cases. Am Surg. 1994;60(6):441-446.

3. Zaliekas J, Munson JL. Complications of gallstones: the Mirizzi syndrome, gallstone ileus, gallstone pancreatitis, complications of “lost” gallstones. Surg. Clin. North Am. 2008;88(6):1345-1368, x.

4. Doko M, Zovak M, Kopljar M, et al. Comparison of Surgical Treatments of Gallstone Ileus: Preliminary Report. World Journal of Surgery. 2003;27(4):400-404.

5. Tan Y, Wong W, Ooi L, others. A comparison of two surgical strategies for the emergency treatment of gallstone ileus. Singapore Med J. 2004;45(2):69–72.

6. Redaelli CA, Büchler MW, Schilling MK, et al. High coincidence of Mirizzi syndrome and gallbladder carcinoma. Surgery. 1997;121(1):58-63.

7. Shiwani MH, Ullah Q. Laparoscopic enterolithotomy is a valid option to treat gallstone ileus. JSLS. 2010;14(2):282-285.

8. van Hillo M, van der Vliet JA, Wiggers T, et al. Gallstone obstruction of the intestine: an analysis of ten patients and a review of the literature. Surgery. 1987;101(3):273-276.

9. Clavien PA, Richon J, Burgan S, Rohner A. Gallstone ileus. Br J Surg. 1990;77(7):737-742.

10. Brennan GB, Rosenberg RD, Arora S. Bouveret Syndrome1. Radiographics. 2004;24(4):1171 -1175.

11. Lasson A, Lorén I, Nilsson A, Nirhov N, Nilsson P. Ultrasonography in gallstone ileus: a diagnostic challenge. Eur J Surg. 1995;161(4):259-263.

12. Lassandro F, Romano S, Ragozzino A, et al. Role of helical CT in diagnosis of gallstone ileus and related conditions. AJR Am J Roentgenol. 2005;185(5):1159-1165.

www.downstatesurgery.org