Gallstone Ileus: Diagnostic and Surgical Dilemma

Vincenzo Leone

Abstract


Background: The typical patient with Gallstone ileus is female, elderly, with concomitant medical diseases and high operative risk. This disease is becoming more common as a result of increase the aging population. Its diagnosis is difficult and early diagnosis could reduce the mortality. Nowadays the use of new imaging techniques can expedite the correct diagnosis, decreasing preoperative delay. However, controversy persists primarily in relation to surgical strategy.

Methods: We retrospectively reviewed the medical records of all patients with the diagnosis of intestinal obstruction between 1998 and 2011. We took into consideration concomitant medical conditions, previous history of cholelithiasis, operative risk (ASA score), preoperative findings, duration and type of surgery, post-operative outcome, 30-day mortality.

Results: The incidence was 0.66% (4 out of 601 cases of intestinal obstruction), 1% if we consider small bowel obstruction only (399 cases), 2.01% in patients over the age of 65 (199 out of 601) and 3.73 % in patients over the age of 80 (107 out of 601). In cases of small bowel obstruction resulting in impacted foreign body the incidence was 36.36 %. All patients were female with a mean age of 81.7 (range 75 - 86). The proper diagnosis prior to surgery was assessed in 2 out of 4 cases. In one case enterolithotomy was completed in one stage with cholecystectomy and closure of the fistula during acute surgery, while in 3 cases enterolithotomy alone was performed, 1 patient operated enterolithotomy alone died on the 14th postoperative.

Conclusions: The history, clinical, and radiologic findings are often nonspecific suggesting only a small bowel obstruction. Nowadays the use of new imaging techniques, in combination with plain abdominal radiographs, can expedite the correct diagnosis in over 50% of cases decreasing preoperative delay. The type of intervention does not significantly influence post-operative morbidity and mortality rates. We believe to perform simple enterolithotomy as procedure of choice, while the one-stage procedure should be performed in patients with greater life expectancy, less operative risk and comorbidity.




doi:10.4021/jcs87w


Keywords


Gallstone ileus; Bilioenteric fistula; Enterolithotomy; Pneumobilia

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