UNUSUAL CASE OF ACUTE ABDOMEN: GALLSTONE ILEUS

Cholelithiasis is the cause of many acute pathological conditions that generally range from biliary colic to pancreatitis.
In rare cases, following an iatrogenic cause, but more often spontaneously, repeated inflammatory processes result in formation of a biliary-digestive fistula between the gallbladder or bile duct and a segment of bowel, with migration of gallstones through the fistula.
The consequence is obstruction of a segment of bowel known as gallstone ileus which represents from 1% to 3% of cases of bowel obstruction.
Usually the gallstone is wedged in the final section of the ileum before the valve of Bauino due to the decrease in size and elasticity, although rare locations in duodenal-jejunal flexure (Bouveret syndrome) have been described.
Initially the gallstone is not usually of such volume to cause the occlusion, but tends to increase in diameter during the stay in the gut with the addition of enteric material. Most of the gallstones tend to pass into the colon and are eliminated without giving any symptoms, but in case of occlusion, two or more stones are found in the ileum.
This uncommon cause of acute abdomen predominantly affects elderly female patients, and only occasionally is diagnosed preoperatively.
Clinically, gallstone ileus is manifested by acute abdominal pain, vomiting and typical objective and radiographic signs of small bowel obstruction.
The average duration of symptoms is 6 days (range 2-14) with an average diagnostic delay of 3.5 days (range 1-10).
The clinical syndrome has a characteristic evolution presenting with hyper acute occlusion followed by spontaneous resolution, due to mobilization of the gallstone resulting from antiperistaltic movements, and subsequent exacerbation of symptoms (tumbling syndrome).
The preoperative diagnosis, if suspected from the medical history and from the direct X-Ray examination of the abdomen, is definitively confirmed with a CT scan, which is the diagnostic gold standard for this condition. This test not only shows the presence of intrahepatic air suggestive of biliary-digestive fistula, even more clearly that on the direct x-ray examination, but is often also able to highlight the presence and location of the fistula itself.
Only the presence of gallstones, in association with the presence of air-fluid levels in the ileum, allows the diagnosis of gallstone ileus.
The following conditions should be considered in the differential diagnosis:
intussusception, obstruction from internal hernia, caecal volvulus, intramural hemorrhage of the small bowel, foreign bodies in the intestinal lumen, diverticulitis of the small bowel, hemoperitoneum, abdominal tumors, and torsion of the gallbladder.
The optimal surgical procedure is still debated.
In younger patients in good general conditions, hemodynamically stable, with low anesthesia risk (ASA 2), and with early diagnosis, a one stage procedure consisting of enterolithotomy and
cholecystectomy with fistula repair is indicated.
In older patients with serious associated diseases, hemodynamically unstable, with significant anesthesia risk (ASA 3), and with late diagnosis, the simple removal of the gallstone, or a two stages procedure (enterolithotomy followed by cholecystectomy and possible repair of the fistula at a later time) are preferable.
The postoperative hospital stay after the enterolithotomy alone is 14 days (range 6-31), compared to 19 days (range 5-28) after enterolithotomy, cholecystectomy and repair of the fistula.
The surgical procedures performed in one and two stages, for patients with gallstone ileus in low-and high-risk respectively, are generally not burdened by significant mortality.
Some authors report the possible advantages of a simple laparoscopic enterolithotomy, especially in elderly patients anesthesia risk ASA3.

REFERENCES

1. Zaliekas J, Hunson JL.Complications of gallstones: The Mirizzi syndrome, gallstone ileus, gallstone pancreatitis, complications of "Lost" gallstones. Surg Clin North Am Dec, 88 (6) :1345-68.
2. Riaz N, Khan MR, Tayeb M. Gallstone ileus: retrospective review of a single center's experience using two surgical procedures. Singapore Med J 2008 Aug; 49 (8) :624-6.
3.Chatterjee S, Chaudhuri T, Ghosh G, Ganguly A. Gallstone ileus.An atypical presentation and unusual location. Int J Surg 2008 Dec; 6 (6), and 55-6. Epub 2007 Feb 16.
4.Pangan JC, Estrada R, Rosales R. Cholecystoduodenocolic fistula with recurrent gallstone ileus. Arch Surg 1984 Oct; 119 (10) :1201-3.