Journal of Digestive Diseases 2009; 10; 149151

doi: 10.1111/j.1751-2980.2009.00378.x

CASE Case Recurrent JEF Fitzgerald Report REPORT gallstone et al. ileus Blackwell Melbourne, Chinese CDD 1751-2980 1443-9611 Journal XXX 2009 The compilation Journal Publishing Authors Australia of Digestive Asia 2009 Chinese Diseases Medical Association Shanghai Branch, Chinese Society of Gastroenterology and Blackwell Publishing Asia Pty Ltd.

Recurrent gallstone ileus: time to change our surgery?

J Edward F FITZGERALD,* Lucy A FITZGERALD,* Charles A MAXWELL-ARMSTRONG* & Adam J BROOKS* *Department of Gastrointestinal Surgery, and Medical Education Unit, University of Nottingham Medical School, Nottingham University Hospital, Nottingham, UK

INTRODUCTION Gallstone ileus was rst described by Bartolin in 1654, and it remains an uncommon cause of small bowel obstruction. Optimal surgical management is controversial. Gallstone ileus arises when an inamed gallbladder adheres to adjacent bowel, forming a biliary-enteric stula which allows stones to pass into the intestinal tract. This commonly occurs at the duodenum, although colonic connections have also been described.1 Rarely, the stone may give rise to Bouverets syndrome, where impaction in the duodenum causes symptoms of gastric outlet obstruction.2 Of increasing importance due to greater life expectancy, gallstone ileus is a disease of the elderly and is more frequent in women. While it accounts for 13% of cases of mechanical small bowel obstruction overall, this increases with age to represent 25% in over the 65s.3 In this group mortality is high at 25%, largely attributable to associated medical comorbidities. Recurrence is infrequent, with only 5% of patients experiencing further episodes.4 In this article we present a rare case of recurrence, and in the light of this we discuss the differing surgical strategies available for treatment of the primary presentation. CASE REPORT A 71-year-old man was admitted with a short history of abdominal pain and vomiting. He had previously
Correspondence to: JEF FITZGERALD, Medical Education Unit, University of Nottingham Medical School, Derby Road, Nottingham, NG7 2UH, UK. Email: edwardtzgerald@doctors.org.uk 2009 The Authors Journal compilation 2009 Chinese Medical Association Shanghai Branch, Chinese Society of Gastroenterology and Blackwell Publishing Asia Pty Ltd.

been diagnosed with gallstones, ischemic heart disease and an abdominal aortic aneurysm (AAA). Examination revealed a soft, distended abdomen with tenderness in the right upper quadrant. His distal pulses were normal. His observations were stable, allowing an abdominal computed tomography (CT) angiogram to be performed (Fig. 1). This conrmed an infra-renal AAA measuring 5.4 cm with no leak. However, dilated loops of uidfilled small bowel together with an intraluminal calcied lesion suggested a diagnosis of gallstone ileus. A second large gallstone was visualized within the gallbladder (Fig. 2). The patient underwent emergency laparotomy where a gallstone was removed from the jejunum. The bowel was otherwise healthy. He subsequently made an uncomplicated recovery and was discharged home with a plan for elective cholecystectomy.

Figure 1. Abdominal computed tomography angiogram showing infra-renal abdominal aortic aneurysm, dilated small bowel loops and a gallstone in the small bowel.

149

150

JEF Fitzgerald et al.

Journal of Digestive Diseases 2009; 10; 149151

Figure 4. The laparotomy. Figure 2. Abdominal computed tomography angiogram showing a large gallstone retained in the gallbladder.

second

gallstone

removed

at

repeat

DISCUSSION Even in the presence of a bilary-enteric stula, obstruction is uncommon with up to 80% of stones being passed spontaneously.5 However stones with a diameter 2 cm are more likely to cause a true mechanical obstruction, and the term gallstone ileus is therefore confusing.6 Often the stone periodically obstructs as it passes through the small bowel, presenting with episodic symptoms of several days duration; a phenomenon termed tumbling obstruction and one that frequently delays diagnosis. Non-specic symptoms along with an unremarkable physical examination between these episodes contribute to the delay. Complete obstruction typically occurs when the stone lodges in the narrower terminal ileum. Riglers triad, the classic radiological signs of air in the biliary tree, small bowel obstruction and a dystopic stone also allow for correct diagnosis but have been reported in as few as 20% of patients. Two surgical strategies have been described for the primary presentation: enterolithotomy alone, allowing a delayed cholecystectomy after an inammation-free period of 46 weeks (and therefore two-stage surgery) or enterolithotomy in combination with a cholecystectomy and stula division (one-stage surgery). Controversy surrounds which of these is more appropriate, and due to the infrequent nature of cases, little research exists to aid decision-making. Many surgeons advocate enterolithotomy alone as an emergency procedure, as it is faster and less technically demanding, with a very low risk of recurrence in the interval before delayed cholecystectomy. Some researchers argue that a subsequent cholecystectomy may not even be required in asymptomatic patients.3 However, it is important to note the increased incidence

Figure 3. Abdominal computed tomography showing a calcied lesion in a pelvic small bowel loop.

Six days later he re-presented with diffuse abdominal pain and vomiting. On examination he had a soft, distended abdomen with generalized tenderness. He was admitted for treatment of presumed postoperative ileus, however, he failed to settle and further radiological imaging was requested (Fig. 3). An abdominal CT revealed a 21-mm stone in the small bowel. The stone previously noted in the gallbladder was now missing. A diagnosis of recurrent gallstone ileus was made and at laparotomy a gallstone was found (Fig. 4) occluding the bowel at the suture line from his previous enterotomy. The patient subsequently made an uncomplicated recovery and was discharged 8 days later.

2009 The Authors Journal compilation 2009 Chinese Medical Association Shanghai Branch, Chinese Society of Gastroenterology and Blackwell Publishing Asia Pty Ltd.

Journal of Digestive Diseases 2009; 10; 149151 of gallbladder cancer among patients with stulas (15%) relative to those without (0.8%). for those undergoing cholecystectomy.7 Proponents of the one-stage procedure argue that although the operation is signicantly longer (mean 2.6 h vs 1.5 h operating time in one series),8,9 the denitive correction of biliary tract disease alongside enterolithotomy prevents future biliary complications such as recurrence, cholangitis, cholecystitis and potential malabsorption due to the presence of a cholecystocolic stula. However, recurrent biliary symptoms following simple enterolithotomy are uncommon,10 and many stulas will close spontaneously. Those supporting the one-stage procedure argue that a second operation for cholecystectomy increases overall exposure to anesthesia and time in hospital. Many elderly patients will also go on to decline a further operation. However, the one-stage operation is undoubtedly a more technically demanding procedure and its disadvantages include the risk of postoperative biliary or an enteric leakage after stula closure, and the exacerbation of local inammation in an already acutely inamed right upper quadrant. Consequently most proponents advise that such a procedure should be performed only in good-risk patients who are adequately resuscitated, and where local and surgical conditions are deemed appropriate. Such patients with gallstone ileus are uncommon, and a recent case series of 22 patients reported that 86.4% of were assessed as ASA class 3 or 4 (the American Society of Anesthesiologists grading for severe medical comorbidity that increases the risk of anesthesia and surgery).11 In elderly patients with a marked physiological disturbance this, together with the extended operating time, leads many surgeons to prefer the two-stage procedure. In addition, reported morbidity and mortality gures differ greatly for the two procedures. Whilst some authors have shown no signicant differences between the operations,3,9 others report a mortality for one-stage procedures of 16.9% versus 11.7% for the two-stage procedure. Similarly, morbidity has been reported as 61.1% for one-stage versus 23.7% for two-stage.4,12 Finally, regardless of the choice of surgical procedure, stone extraction using a laparoscopic technique is of diagnostic as well as therapeutic value. This is likely to nd greater acceptance as laparoscopic skills develop further over the coming years. The reduction in surgical

Recurrent gallstone ileus

151

trauma associated with laparoscopic procedures may particularly benet the elderly population most commonly affected with gallstone ileus, and successful procedures have now been reported in a small number of cases.13,14 CONCLUSIONS The different strategies for surgical management are likely to remain controversial and given current evidence in this area we would advocate considering each patient on an individual basis. In the case described here the risks associated with the patients signicant comorbidities were judged to outweigh the potential benets of performing a one-stage procedure. However, clinicians need to be aware of the different options and alert to the occasional risk of recurrence with enterolithotomy alone in two-stage surgery. REFERENCES
1 Stewart DJ, Lobo DN, Scholeeld JH. Colonic gallstone ileus. J Am Coll Surg 2003; 196: 154. 2 Koulaouzidis A, Moschos J. Bouverets syndrome. Narrative review. Ann Hepatol 2007; 6: 8991. 3 Clavien PA, Richon J, Burgan S, Rohner A. Gallstone ileus. Br J Surg 1990; 77: 73742. 4 Reisner RM, Cohen JR. Gallstone ileus: a review of 1001 reported cases. Am Surg 1994; 60: 4416. 5 Piedad OH, Wels PB. Spontaneous internal biliary stula, obstructive and nonobstructive types: twenty-year review of 55 cases. Ann Surg 1972; 175: 7580. 6 Deitz DM, Standage BA, Pinson CW, McConnell DB, Krippaehne WW. Improving the outcome in gallstone ileus. Am J Surg 1986; 151: 5726. 7 Bossart PA, Patterson AH, Zintel HA. Carcinoma of the gallbladder. A report of seventy-six cases. Am J Surg 1962; 103: 3669. 8 Zuegel N, Hehl A, Lindemann F, Witte J. Advantages of one-stage repair in case of gallstone ileus. Hepatogastroenterology 1997; 44: 5962. 9 Tan YM, Wong WK, Ooi LL. A comparison of two surgical strategies for the emergency treatment of gallstone ileus. Singapore Med J 2004; 45: 6972. 10 Simsa J, Lefer J, Charvt D, Grabec P, Hoch J. Gallstone ileus rare disease and still many discrepancies. Eur Surg 2006; 38: 30711. 11 Ayantunde AA, Agrawal A. Gallstone ileus: diagnosis and management. World J Surg 2007; 31: 12927. 12 Doko M, Zovak M, Kopljar M, Glavan E, Ljubicic N, Hochstadter H. Comparison of surgical treatments of gallstone ileus: preliminary report. World J Surg 2003; 27: 4004. 13 Agresta F, Bedin N. Gallstone ileus as a complication of acute cholecystitis. Laparoscopic diagnosis and treatment. Surg Endosc 2002; 16: 1637. 14 Allen JW, McCurry T, Rivas H, Cacchione RN. Totally laparoscopic management of gallstone ileus. Surg Endosc 2003; 17: 352.

2009 The Authors Journal compilation 2009 Chinese Medical Association Shanghai Branch, Chinese Society of Gastroenterology and Blackwell Publishing Asia Pty Ltd.