Francesco Pata, MD, PhD, of Università della Calabria in Rende, Italy, and his team were faced with a diagnostic dilemma when a 70-year-old woman presented with abdominal pain, nausea, and vomiting for the past 3 days. The patient had a medical history of high blood pressure, atrial fibrillation, and congestive heart failure. However, she had not undergone any abdominal surgery.
Symptoms and Diagnosis
On physical examination, the patient was afebrile, but her blood pressure was 80/60 mm Hg, and her heart rate was 122/min. Her abdomen was distended and tympanic, with diffuse tenderness to palpation. Lab tests revealed abnormalities in white blood cell count, C-reactive protein, potassium, and creatinine. The team administered a 500 mL bolus of intravenous crystalloid fluid and 1 g of intravenous ceftriaxone, and placed a nasogastric tube, which produced initial drainage of 300 mL of biliary fluid. A non-contrast-enhanced abdominal CT scan showed a thickened gallbladder with intraluminal air and gallstones adherent to the duodenum with a suspected fistula tract. The team diagnosed gallstone ileus.
Characteristics of Cholecystoenteric Fistula
Pata and co-authors explained that the combination of an ectopic gallstone in the small bowel and a thickening of the gallbladder wall with intraluminal air adherent to the duodenum is characteristic of a cholecystoenteric fistula. The team planned to perform a surgical intervention when the patient’s condition stabilized.
Treatment Options and Management
The patient was admitted to the intensive care unit (ICU), where she received 3 L of intravenous fluid resuscitation over 12 hours. The team performed a midline laparotomy and enterolithotomy and removed a 2.7 cm gallstone that had been obstructing the middle ileum. A 3-cm ileal resection with a hand-sewn side-to-side anastomosis was performed due to evidence of mild ischemic changes in the posterior wall of the ileum. After 3 days in the ICU for monitoring, the patient was discharged to home on postoperative day 8. A follow-up appointment 1 month later showed the patient to be free of symptoms, with a normal serum creatinine level. Clinicians referred her to a hepatobiliary surgical specialist for follow-up and care management.
Gallstone Ileus: A Mechanical Obstruction
Gallstone ileus is a mechanical obstruction caused by the migration of a gallstone from the gallbladder through a biliary-enteric fistula into the gastrointestinal tract. A fistula usually develops when inflammation from repeated episodes of cholecystitis cause the gallbladder to adhere to surrounding organs. Gallstones generally advance from the gastrointestinal tract, and small stones are expelled through the rectum, but gallstones larger than 2 cm may obstruct the intestine. The presenting symptoms of gallstone ileus tend to include nausea, vomiting, abdominal pain, and distension, and may occur sporadically as the gallstones move along the gastrointestinal tract. The condition is typically treated with surgery because the intestinal obstruction rarely resolves spontaneously.
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