Presenter: Anna Meyendorff, MD
Author: Fernando Barajas, MD
CC: Epigastric pain
Vitals BP 154/87, HR 64, RR 20, Sat 95% RA
-ROS: Denies diarrhea, constipation (normal BM 2 days ago), dysuria, diaphoresis, fevers, chills, chest pain
PMHX: Cholecystitis managed with Cholecystostomy. HTN, DM, nephrolithiasis
Meds: ASA, Coreg, losartan, zocor, nifedipine, chlorthalidone, imdur, flomax, metformin, prilosec, trazodone, citalopram, abilify,
SH: Denies toxic habits
Physical Exam:
Appears uncomfortable though AOX3. Frequent belching
RRR without murmurs
Lungs CTAB/L
Abd: soft, non-distended, ?tenderness that is distractible. NO rebound or guarding
Extremities WWP
DDX
- Vascular: MI, AAA, Aortic dissection, mesenteric ischemia
- Infectious/Inflammatory: Pneumonia, biliary disease (chole, cholangitis, colic), hepatitis, pancreatitis, gastritis, gastroenteritis
- Small/Large bowel obstruction, diverticulitis
Labs
12.2>12.3/36.6<166
146/3.3/105/30.1/27/1.7<136
T.bili 0.7, alk phop-7.5, AST/ALT 12/18, lipase 36,
trop 0.013 (ref range < 0.08)
lactate 1.4
CT abd/pelvis: Migration of large gallstone into the bulb of the duodenum causing gastric outlet obstruction. Fistulous communication between gallbladder, duodenum, and hepatic flexure of the colon.
Management: Pt refused operative clearance by cardiology hence interventions delayed. He had EGD on HOD#5 at which point the stone had migrated. He then had another X-ray showing SBO. Ex-lap performed to remove obstructing stone and repair enterotomy.
- Is the end result of cholelithiasis and as a gross simplification can be depicted as follows. This discussion will focus on gallstone ileus
- Disproportionately affects women in their 50-70s
- Estimates indicate gallstones account for “0.5-3% of mechanical bowel obstruction”
- Mortality rate: 15-18%
- Large stones lead SBO (stone obstructing at the terminal ileum or colon) or gastric outlet obstruction
- Fistulas, on the other hand, present with vague symptoms though could be associated with fevers and chills from transposition of enteric flora into the biliary tree. They may also have nausea and diarrhea because of loss of bile
- LFTs—non-specific, though the labs will be consistent with biliary obstruction if they have Mirizzi’s syndrome (external obstruction of CBD)
- CBC/BMP: +/- leukocytosis, electrolyte abnormalities
- Plain film+ CT abd/pelvis:
- Rigler’s Triad: Pneumobilia, bowel obstruction, calcified gallstone
- 2/3 findings seen in 20-50% of cases on plain films
- 93% sensitivity for gallstone ileum with CT.
- Rigler’s Triad: Pneumobilia, bowel obstruction, calcified gallstone
- Decompression, IVF, pain control
- Debate in literature between one-stage surgery (fistula repair, cholecystectomy, enterolithotomy all at once) and two-stage surgery (enterolithotomy followed by cholecystectomy).
- Keaveny AP, Afdhal NH, Bowers S. Uptodate,Chen W (Ed), UpToDate, Waltham, MA. (Accessed on Dec 5, 2015. Last edited Nov 11, 2015)
- Luu MB, Deziel DJ. Unusual complications of gallstones. Surg Clin North Am2014;94:377–94.
- Wong CS, Crotty JM, Naqvi SA. Pneumobilia: A Case Report and Literature Review on its Surgical Approaches. J Surg Tech Case Rep. 2013 Jan-Jun; 5(1): 27–31.