A case of recurrent gallstone ileus: the fate of the residual gallstone remains unknown

Abstract

SUMMARYGallstone ileus is a serious complication of cholelithiasis where mechanical small bowel obstruction occurs. The recurrence of gallstone ileus is rare. The 67-year-old woman in this case report had three known gallstones transit her small bowel with two causing obstruction and the third causing a 'tumbling phenomenon'. As we have an ageing population, and gallstone ileus has a higher incidence in the over 65 age group, associated with increased comorbidities and hence greater mortality rates, it is imperative to establish the best surgical intervention for it. This case report highlights the difference CT of the abdomen has made to the diagnosis of gallstone ileus and the pros and cons of the surgical management options. BACKGROUND

Feasibility of Laparoscopic-Assisted Approach in Management of Gallstone Ileus

“…2 It occurs when a gallstone becomes lodged between the gallbladder and the bowel, and forms a cholecystoenteric fistula, which allows passage of gallstone into bowel where it becomes impacted. 2,3 The morbidity and mortality of gallstone ileus remains remarkably high likely because of delayed diagnosis and the typically frail nature of these patients. Often the diagnosis is delayed because symptoms can be intermittent and nonspecific, and initial investigations may fail to identify the cause of obstruction until the disease progresses.…”

“…Most of these gallstones impact in the terminal ileum because it is the narrowest segment of the intestine and because of less peristaltic activity at that location. 2,3 The chronic erosive gallbladder wall leads to tissue adhesion to adjacent hollow organs, eventually forming the cholecystoenteric fistulas, most commonly to the duodenum. The gallstones passes into the bowel lumen and block the narrowest intestinal segment (50-75%), the terminal ileum, and ileocecal valve.…”

“…4 As a general rule, the larger the stone the more proximal the obstruction. 3 A preoperative diagnosis of gallstone ileus is challenging. Often times a delay in the diagnosis of gallstone ileus is due to the "tumbling phenomenon," where the stone stumbles through portions of gastrointestinal tract causing intermittent crampy abdominal pain, variable distension, nausea, vomiting, and constipation intermittently.…”

“…There are presently three main options: 1) Enterolithotomy alone; 2) One-stage surgery: enterolithotomy, cholecystectomy, and fistula repair; 3) Two-stage surgery: enterolithotomy and delayed cholecystectomy. 2,3 Some support the more conservative approach of a single enterolithotomy, whereas others support a two-stage procedure. Studies conducted to assess the outcomes of the more aggressive surgical approach versus a more conservative approach have suggested that a more conservative approach limits complications from a bigger operation.…”

Laparoscopic Management of a Proximal Jejunal Gallstone Ileus with Patulous Ampulla and Choledochal Cyst—a Report of Unusual Presentation and a Review

“…Although it has been observed as a de novo complication of long-standing gallstone disease, it has also been seen postoperatively even after cholecystectomy [20,34], hepaticojejunostomy [11], choledocho-duodenostomy, or cholecysto-jejunal anastomosis in bilio-enteric bypass for morbid obesity as reported by Micheletto et al [35]. The recurrent episodes of gallstone ileus can occur if the pathology is not treated at the first occasion [36][37][38].…”