Evolving Gallstone Ileus. SUNY Downstate Case Conference January 12, 2012

Transcription

1 Evolving Gallstone Ileus SUNY Downstate Case Conference January 12, 2012

2 Initial Presentation HPI: 90 yo F c 1wk h/o abdominal pain and N/V. Denied F/C. Passing flatus/bm. PMH: DM, HTN, CAD. PSH: C-sections x 3. Meds: Enalapril, HCTZ, Plavix, Colace

3 Exam VS: / %RA WDWD, NAD RRR CTAB Soft, mildly distended, nontender. Well healed Pfannenstiel scar.

4 Labs CBC 4.9 / 10 / 32 / 290 BMP 139 / 3.5 / 103 / 24 / 11 / 0.83 / 198 Amy 37 / Lip 5 AST 21 / ALT 16 / TB 0.5

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7 Hospital Course Admitted for observation. Negative MRCP. Symptoms resolved. Discharged to home on regular diet.

8 Second Presentation Returned to ED 3 days post d/c, with recurrence of symptoms. Exam unchanged. Labs CBC 6.3 / 12 / 38 / 271 BMP 137 / 5.4 / 100 / 26 / 14 / 0.78 / 122 Amy 53 / Lip 15

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11 Hospital Course Readmitted for observation. Symptoms resolved; tolerated diet. At 1 week, abrupt ab distention, N/V.

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14 Operative Intervention Underwent uneventful enterolithotomy. Remaining bowel unremarkable. Dense adhesions in the RUQ.

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16 Hospital Course Started diet POD 7. Postop course complicated by refractory afib/flutter. Discharged to rehab facility POD 22.

17 Questions

18 Gallstone Ileus Mechanical obstruction caused by intraluminal impaction of one or more gallstones anywhere between the stomach and the rectum. S/Sx frequently nonspecific. Elderly patient with comorbid conditions.

19 Epidemiology 1-4% of all cases of intestinal obstruction in general population. 25% of nonstrangulated SBO over age of 65. Mean age 65 to 75. Accurate preop diagnosis in 24 to 73% of cases. Reisner RM, et al. Am Surg. 1994;60(6):

20 Pathogenesis 60-80% have demonstrable bilioenteric fistula. 60% cholecystoduodenal fistulas 20-30% have complex RUQ mass on laparotomy. Fistulas can occur between the biliary tree and stomach, small bowel, large bowel. Bilioenteric fistulas may be associated with surgery, gall bladder carcinoma, duodenal ulcers, and IBD. van Hillo M, et al. Surgery. 1987;101(3):

21 Related Eponyms Mirizzi Syndrome Bouveret Syndrome Rigler s Triad

22 Related Eponyms Mirizzi Syndrome Common hepatic duct or CBC obstruction caused by compression from GS in cystic duct or Hartmann s pouch Bouveret Syndrome Gastric outlet obstruction caused by GS impaction in distal stomach or duodenum Rigler s Triad Bowel obstruction, pneumobilia, ectompic gallstone.

23 Anatomy Stones may pass spontaneously through Ampulla of Vater. 90% of obstructing GS > 2cm in diameter. Impaction occurs in: Ileum 60.5% Jejunum 16.5% Stomach 14.2% Colon 4.1% Duodenum 3.5% Clavien PA, et al. Br J Surg. 1990;77(7):

24 Presentation Abdominal pain, distention, and vomiting. Obstruction 50-70%. Frequently, intermittent. Tumbling obstruction. Previous hx of gallstone disease did not contribute to diagnosis. van Hillo M, et al. Surgery. 1987;101(3):

25 Signs and Symptoms

26 Radiographic Findings Air/contrast in biliary tree. Visualization of stone in the intestine. Change in position of previously identified stone. Partial or complete obstruction.

27 Other Studies Plain X-ray US May demonstrate pneumobilia, enterolith. May be useful in identifying fistula or enterolith movement during bowel peristalsis. Endoscopy May directly identify fistula. Lasson A, et al. Eur J Surg. 1995;161(4): Lassandro F, et al. AJR Am J Roentgenol. 2005;185(5):

28 AXR

29 CT

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32 Endoscopy

33 Treatment Surgery enterolithotomy (open vs laparoscopic). Inspection of entire bowel (small and large). Multiple stones have been reported in 3-40% of Pts. Extracorporeal shockwave lithotripsy successfully employed. Ravikumar R, et al. Ann R Coll Surg Engl. 2010;92(4):

34 Cholecystenteric Fistula 1 Stage enterolithotomy, cholecystectomy, fistula repair. 2 Stage enterolithotomy.

35 1 Stage Prevents recurrence. Up to 17% have recurrent GSI. Prevents cholecystitis, cholangitis. GB Ca higher in Pts with cholecystenteric fistula. Clavien PA, et al. Br J Surg. 1990;77(7): Redaelli CA, et al. Surgery. 1997;121(1):58-63.

36 2 Stage Most consider enterolithotomy sufficient. Pt population high risk. Recurrence low less than 5% Reoperation rate less than 10% Increased morbidity and mortality. Doko M, et al. World Journal of Surgery. 2003;27(4): Reisner RM, et al. Am Surg. 1994;60(6): Tan Y, et al. Singapore Med J. 2004;45(2):69 72.

37 Take-Aways GSI may be the source of unusual presentations of pneumobilia, SBO, or abdominal pain. For the typical GSI Pt, enterolithotomy is sufficient. Inspect entire small bowel for multiple GS.

38 References 1. Ravikumar R, Williams JG. The operative management of gallstone ileus. Ann R Coll Surg Engl. 2010;92(4): Reisner RM, Cohen JR. Gallstone ileus: a review of 1001 reported cases. Am Surg. 1994;60(6): Zaliekas J, Munson JL. Complications of gallstones: the Mirizzi syndrome, gallstone ileus, gallstone pancreatitis, complications of lost gallstones. Surg. Clin. North Am. 2008;88(6): , x. 4. Doko M, Zovak M, Kopljar M, et al. Comparison of Surgical Treatments of Gallstone Ileus: Preliminary Report. World Journal of Surgery. 2003;27(4): Tan Y, Wong W, Ooi L, others. A comparison of two surgical strategies for the emergency treatment of gallstone ileus. Singapore Med J. 2004;45(2): Redaelli CA, Büchler MW, Schilling MK, et al. High coincidence of Mirizzi syndrome and gallbladder carcinoma. Surgery. 1997;121(1): Shiwani MH, Ullah Q. Laparoscopic enterolithotomy is a valid option to treat gallstone ileus. JSLS. 2010;14(2): van Hillo M, van der Vliet JA, Wiggers T, et al. Gallstone obstruction of the intestine: an analysis of ten patients and a review of the literature. Surgery. 1987;101(3): Clavien PA, Richon J, Burgan S, Rohner A. Gallstone ileus. Br J Surg. 1990;77(7): Brennan GB, Rosenberg RD, Arora S. Bouveret Syndrome1. Radiographics. 2004;24(4): Lasson A, Lorén I, Nilsson A, Nirhov N, Nilsson P. Ultrasonography in gallstone ileus: a diagnostic challenge. Eur J Surg. 1995;161(4): Lassandro F, Romano S, Ragozzino A, et al. Role of helical CT in diagnosis of gallstone ileus and related conditions. AJR Am J Roentgenol. 2005;185(5):