The Oldest Patient with Gallstone Ileus: Report of a Case and Review of 176 Cases in Japan

Abstract

Summary:We report a 91-year-old woman presenting bowel obstruction due to impacted gallstone, who was the oldest patient which has been reported in Japanese scientific literature. The patient was referred to our hospital due to vomiting and abdominal pain. Computed tomography and abdominal X-ray showed dilated loops of small intestine associated with air-fluid levels, pneumobilia, and a calcified mass in the left iliac fossa. After the diagnosis of bowel obstruction due to gallstone was made, an enterotomy and lithotomy was performed under spinal anesthesia. The postoperative recovery was uneventful. We also reviewed 176 cases of gallstone ileus which were reported in the Japanese literature in the past 20 years. The retrospective analysis demonstrated that one-stage enterolithotomy alone may be acceptable as the first choice of operative treatment. The gallstone ileus is a rare, but important disease because urgent and appropriate surgical therapy is required.

Laparoscopic-Assisted Enterolithotomy for Gallstone Ileus

“…In most of the reported cases, mechanical, electrohydraulic, or laser lithotripsies have been used to fragment the stone [9][10][11]. ESWL has also been used at times for stone fragmentation [11,12].…”

“…In most of the reported cases, mechanical, electrohydraulic, or laser lithotripsies have been used to fragment the stone [9][10][11]. ESWL has also been used at times for stone fragmentation [11,12]. The stone fragments are either removed endoscopically or they get passed spontaneously in the stools, but it carries the risk of recurrent symptoms or distal obstruction [10].…”

“…Conservative medical treatment is reserved for patients with several comorbidities with obstructing gallstone of less than 2 cm as it is likely to get passed off spontaneously [11].…”

Gallstone Ileus: Diagnostic and Surgical Dilemma

“…However, the one-stage-procedure is desirable if the condition of the patient allows it. Conservative therapy may also be considered for the treatment of GSI when the obstructing gallstone is smaller than 2 cm based on radiological measurement [12]. Instead, the two stage procedure (enterolithotomy initially followed at 4 -6 week by cholecystectomy and repair of the bilio-digestive fistula) should be performed only for symptomatic patients or patients developing complications during follow-up.…”

Enterolithiasis

“…This condition arises in estimated 0.3%-0.5% of general cholelithiasis [31,32] . It accounts for approximately 1%-4% of all cases of mechanical bowel obstruction, while significantly increasing to 25% in geriatric population [31,[32][33][34][35][36][37][38][39] . Over-diagnosis of intestinal obstruction due to migrated gallstone has been reported in the literature, largely due to under-recognition of primary "pseudogallstone" enterolithiasis.…”