Journal of Marine Medical Society

CASE REPORT
Year
: 2019  |  Volume : 21  |  Issue : 2  |  Page : 193--195

Gallstone ileus with cholecystoduodenal fistula: Primary repair at a zonal hospital


Bharat Jani1, R Shankaran2,  
1 Department of Surgery, INHS Dhanvantari, Minniebay, Port Blair, Andaman and Nicobar Island, India
2 Department of Surgery, Armed Forces Medical College, Pune, Maharashtra, India

Correspondence Address:
Surg Cdr Bharat Jani
Department of Surgery, INHS Dhanvantari, Minniebay, Port Blair - 744 102, Andaman and Nicobar Island
India

Abstract

We herein report a case of gallstone ileus due to stone at terminal ileum. It is one of the rare complications of chronic cholelithiasis. The patient presented with features of small-bowel obstruction and distension of abdomen. The management dilemma was between simple enterotomy to relieve obstruction and to go for repair of cholecysto-duodenal fistula in addition. Management by only enterotomy as a single procedure has a good prognosis but has chances of recurrence, whereas repair of fistula in addition to enterotomy in the same setting has variable results in terms of morbidity. In this case, the primary repair of fistula was done in the first presentation itself with good results. Hence, primary repair of cholecysto-duodenal fistula is also an option in early presentation with no signs of peritonitis to reduce the morbidity of repeated surgeries.



How to cite this article:
Jani B, Shankaran R. Gallstone ileus with cholecystoduodenal fistula: Primary repair at a zonal hospital.J Mar Med Soc 2019;21:193-195


How to cite this URL:
Jani B, Shankaran R. Gallstone ileus with cholecystoduodenal fistula: Primary repair at a zonal hospital. J Mar Med Soc [serial online] 2019 [cited 2020 Feb 24 ];21:193-195
Available from: http://www.marinemedicalsociety.in/text.asp?2019/21/2/193/268617


Full Text



 Introduction



Gallstone ileus is an important, though infrequent, cause of mechanical bowel obstruction in the ileum due to impaction of a gallstone passing through a biliary-enteric fistula and often affects elderly patients. It occurs in <0.5% of patients and is responsible for approximately 1%–4% of all cases of mechanical small-bowel obstruction.[1] In patients above 65 years of age, it accounts for 25% of nonstrangulated small-bowel obstruction. The average age of patients is 70 years, with the youngest reported patient being 13 years of age. Women are 3–16 times more likely to be affected.[2],[3] The diagnosis is often delayed, and the mainstay of treatment is removal of the obstructing stone after initial resuscitation. This case report is aimed at highlighting the fact that cholecysto-duodenal fistula is the most common accompanying finding in gallstone ileus. It is also stressed that in peripheral hospitals with adequate imaging and laboratory support, these cases may be managed by general surgeons with a meticulous approach and diligent perioperative care.

 Case Details



A 65-year-old woman, known case of cholelithiasis, presented with an acute onset of right hypochondrial pain which was radiating to the back, vomiting, and nausea of 2 days' duration with no history of jaundice, fever, loose stools, obstipation, hematemesis, and malena at the time of obstipation. On the 1st day of admission, her vitals were stable and normothermic and the abdomen was soft with mild tenderness in the right hypochondrium. On the 3rd day, she had obstipation and abdominal distension. Contrast-enhanced computed tomography abdomen images and investigations [Table 1] were suggestive of mechanical small-bowel obstruction, impacted calculus at the distal ileus [Figure 1], and pneumobilia [Figure 2], suggestive of gallstone ileus.{Table 1}{Figure 1}{Figure 2}

Management

She was taken up for exploratory laparotomy, and the site of obstruction showed impacted gallstone of approximately 4-cm size which was removed through a longitudinal enterotomy. Proximal bowel was decompressed, and primary closure of enterotomy was done. The omentum was rolled up around the gallbladder (GB) with almost nonexisting GB wall (merged with duodenum as fistula) and another impacted calculus of approximately 1.5 cm at GB neck which was also removed with gentle finger movements [Figure 3]. The omentum-GB-duodenum complex (the fistula) was isolated and opened.{Figure 3}

The duodenal opening was repaired primarily. The tip of nasogastric tube was brought right up to the second part of the duodenum just near the repair. The duodenal repair was strengthened by omental buttressing as done in Graham's patch repair for duodenal perforation. Cystic duct was located and closed with a nonabsorbable suture.

The abdomen was closed over two drains: a 32-Fr drain placed near duodenal repair, a pelvic drain, and a feeding jejunostomy in the proximal jejunum. The combined drain output gradually decreased from 80 ml (postoperative day [POD] 1) to 10 ml (POD 6) and was pulled out in stages. The patient had an uneventful postoperative recovery and later discharged to home on the 10th day. Follow-up consultation after a month and 3rd month did not reveal any complaints.

 Discussion



Gallstone ileus develops in 0.3%–0.5% of patients with cholelithiasis, and 2%–3% of patients develop biliary enteric fistulas due to constant pressure exerted by the impacted calculus.[4] Among all these fistulas, 60% are cholecystoduodenal fistulas, but cholecystocolonic, cholecystojejunal, and cholecystogastric fistulae are also known. Most of the time, cholecystoduodenal fistula may not necessarily result in gallstone ileus. However, the usual means of obstructing gallstone entry into the bowel is through a pressure necrosis and biliary enteric fistula.[5],[6]

Recurrent transient gallstone obstruction in gut produces “tumbling obstruction,” and the mean duration of symptoms before hospital admission is approximately 5 days.[7] Mirizzi syndrome (common hepatic duct obstruction) and Bouveret's syndrome (gastric outlet obstruction at duodenum) are described secondary to an impacted gallstone. An association between Mirizzi syndrome and the presence of a cholecysto-enteric fistula has been suggested.[8],[9]

Gallstone ileus generally presents with gradual-onset mechanical intestinal obstruction. Management essentially involves identification of the cause, presence of fistula, and closure technique. It is also important to keep the drain near site of closure of fistula and repair of duodenal wall. This is a standby arrangement in case of failure of repair and leak from closure. In this case, in addition to a wide drain at the repair, gastric and biliary drainage was also achieved by putting a Ryle's tube up to the second part of duodenum (placed intraoperatively).

 Conclusion



High index of suspicion is key in diagnosis, and exploratory laparotomy, enterotomy, and relieving obstruction is the definitive management of gallstone ileus. In case the fistula is anteriorly placed, then repair of fistula with cholecystectomy may be attempted by general surgeons. In case of posterior fistula or associated Mirizzi syndrome, if diagnosed on imaging, then it should be best handled at specialist centers. If posterior fistula is diagnosed intraoperatively, then it is suggested to remove the impacted ileal stone and leave a drain at Calot's triangle prior to transfer of the patient to higher center.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

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