Gallstone Ileus. Audrey C. Durrant,, M.D. SUNY Downstate Medical Center May 20, 2005

Transcription

1 Gallstone Ileus Audrey C. Durrant,, M.D. SUNY Downstate Medical Center May 20, 2005

2 Gallstone Ileus Diagnosis and Management

3 Background Misnomer coined by Bartolin in 1654 Not a true ileus True mechanical obstruction in the bowel lumen secondary to the impaction of one or more gallstones Rare cause of small bowel obstruction accounting for 1% - 2% of SBO 1 In the geriatric population, incidence may be as high as 25 percent Bouveret s syndrome unique form in which a gallstone obstructs the gastric outlet (1) Hudspeth AS, McGuirt WF. Gallstone ileus.. A continuing surgical problem. Arch Surg 1970: 100; (2) Lopez-Martine JA. et al.. Bouveret s syndrome. Case reoport

4 Pathophysiology Associated with inflammatory process of acute cholecystitis Body attempts to compartmentalize process by surrounding it with adjacent soft tissues Phlegmon formed is composed omentum and nearby bowel If of sufficient intensity and duration than gall bladder can form a fistulous communication with adjacent hollow organs 3 (3) Gracie WA, Ransohoff DF. The natural history of silent gallstones: the innocent gallstone lstone is not a myth. N Engl J Med 1882, 307;

5 Pathophsiology (cont d) Most common: Cholecysto-duodenal fistula Can also involve colon, stomach or more distal areas small bowel Gallstones involved usually large, >2-3 3 cm Stone enters GI tract via the fistula, migrates distally until it exits rectum or becomes lodged in the narrowest part of the bowel, terminal ileum 4 (4) Clavien PA, Richon J, Burgan S, Rohner A. Gallstone ileus.. Br J Surg 1990: 77;

6 Clinical Presentation Typical patient elderly woman History biliary colic Presents with tumbling bowel obstruction Diagnosis should be suspected in patients with obstruction in absence of an incarcerated hernia or a history of prior abdominal surgery

7 Diagnosis Hard to diagnose previous series yield 43% to 73% diagnosed pre-operatively (6) >50% diagnosed only at laparoscopy (6) Antecedent history of gallstone disease presents only in 50% patients Rigler s Triad (2) : aerobilia, ectopic gallstones and bowel dilatation suggestive but infrequent finding and NOT diagnostic CT scan highly sensitive and accurate in pre-op diagnosis of suspected intestinal obstruction (4)Reisner RM, Cohen JR. Gallstone ileus: : a review of 1001 reported cases. Am Surg 1994; 60:441-6 (5)Rigle LG, Borman CN, Noble JF. Gallstone obstruction. Pathogenesis and roentgen n manifestations. JAMA ; 117: (6)Van Hillo M, van der Vliet JA et al. Gallstone obstruction of the intestine: an analysis of 10 patients and a review of the literature. Surgery 1987;101:23-6 Shrake PD. Rex DK. Et al. Radiographic evaluation of suspected small bowel obstruction. Am J Gastroenterol 1991; 86:

8 Management Uniform surgical not yet clearly defined Debate involves need for definitive biliary tract surgery: Enterolithotomy alone to relieve obstruction with biliary tract surgery later (two stage procedure) or to perform the biliary tract surgery at the same sitting (one stage procedure)

9 Operative Strategy Two stage: : quick relief mechanical obstruction avoid need fistula exploration and reduces operative time -most fistulas close spontaneously if left alone -published reports (7) show lower mortality rate 11% in two stage procedure compared to 16.7 % for one stage procedure One Stage: : more technically difficult reduces occurrence recurrent gallstone ileus, cholecystitis (7) Rodriguez-Sanjuan JC. Et al. Cholecystetomy and fistula closure versus enterolithotomy alone in ileus.. Br J Surg 1997:84:634-7

10 Final Word In a recent study in the Singapore the journal of medicine both surgical methods were used in a single department to determine if there was an advantage of one treatment versus the other 5 Overall there was found to be no significant difference in morbidity or outcome Gallstone ileus is a rare condition as of yet there is no gold standard The two stage procedure is safe in both high and low risk patients and requires a shorter operative time The remnant fistula and gallbladder rarely (<4%) cause future complications (7) (5) Tan YM, Wong WK. A Comparioson of Two Surgical Strategies for the emergency treatment of gallstone ileus. Singapore Med J. 2004