Cholecystoduodenal fistula with subsequent gallstone ileus: case report of an unusual course

Gallstone ileus is a rare complication of cholecystolithiasis with a high mortality because of the advanced age of the patients and the often delayed diagnosis. Signs of a cholecystoduodenal fistula are often absent in conventional ultrasonic and radiological methods. Treatment options are: 1. Enterolithotomy, 2. One stage procedure or 3. Two stage procedure consisting of enterolithotomy and the surgery of the biliary tract. In the case of our patient we performed a conventional cholecystectomy and the closure of the cholecystoduodenal fistula, which was found accidentally. When the gallstone ileus appeared 6 days later the enterolithotomy was performed. Thus in case of accidentally found cholecystoduodenal fistula an exploration of the abdominal cavity and the small intestine to find the gallstone should be performed on principle. Gallstones with a diameter of more than 2-3 cm should be removed by enterolithotomy to prevent the gallstone ileus.     

Biliary ileus

In the period 1946-1987 at the former Second Surgical Clinic of the Medical Faculty in Belgrade 25 patients with a biliary ileus were Surgically treated, 20 females (80%), and 5 males (20%), aged from 53 to 87 years, (mean 67 years). Six patients were decade, 7 in 7th, 9 in 8th, and 3 in 9th decade. In only 8 patients biliary calculosis had been confirmed earlier. Preoperative troubles in the Bowel Passage lasted 1-7 days, (mean 3 days), mostly as in incomplete gut occlusion. Preoperative diagnosis of the biliary ileus, using x-ray, was exact only in 3 cases (12%), while other remaining patients underwent Surgery diagnosed as ileus of the small bowel or acute abdomen. In 7 patients a stone obstructed the jejunum, in 6 ones its widpart and in 10 cases the terminal ileum. In 23 patients an enterotomy distally to the obstruction with an expulsion-extraction was done, in one patient a partial resection of the gut and in another patient a manual stone expulsion into the colon, with no enterotomy, was carried out, and after operation the stone was removed from the rectum. The Bilio-digestive fistula was never treated either the surgery itself, or later. Complications arised in 13 patients: wound infection in 11, deep thrombophlebitis in one and a pneumonia in two patients. An average hospitalization was 27 days, and all patients Survived.     

Treatment of intrahepatic gallstone

The postoperative outcomes in patients with hepatolithiasis are greatly affected by the presence of residual stones. One hundred and seventeen patients with hepatolithiasis treated in our clinic were analysed. The indication of hepatectomy for hepatolithiasis was determined by the degree of stricture of intrahepatic bile duct. The rate of residual stones was reduced from 54.5% to 14.5% by the introduction of choledochoscopical lithotomy. Thus, pre- and postoperative choledochoscopical examination and lithotomy are shown to play an important role in treatment of the patients with hepatolithiasis.     

Pathophysiology of gallstone formation

There are two types of gallstones: cholesterol and pigment stones. The pathogenesis is divided into three phases: supersaturation, nucleation and stone growth. Hypersecretion of biliary cholesterol, crystallization promoting and inhibiting factors, gallbladder hypomotility, arachidonyl lecithin, prostaglandins, mucin and calcium play an important role in the formation of gallstones. For the formation of pigment stones a decreased secretion of biliary acids, an increased secretion of unconjugated bilirubin into the bile and an infection of the biliary tract are the most important causative factors.     

Late ileus in paraplegia

Ileus is a common complication of spinal cord injury, resolving within one week of injury in most cases. Two cases are reported in which the ileus developed as a more serious later complication and proved to be very intractable to treatment. Causes and treatment are discussed.     

Gallbladder emptying and gallstone formation: a prospective study on gallstone recurrence

BACKGROUND & AIMS: Gallbladder emptying is reduced in many patients with cholesterol gallstones. To clarify the role of impaired gallbladder motility in recurrent gallstone disease, the effect of gallbladder emptying on the formation of recurrent stones was studied prospectively. METHODS: In 54 consecutive patients with single radiolucent gallbladder stones, postprandial gallbladder emptying was assessed sonographically before lithotripsy and 1.8 +/- 0.1 years (mean +/- SE) after gallstone disappearance. Patients were followed up for gallstone recurrence for 0.6-4.1 years (median, 2.6 years). RESULTS: After gallstone disappearance, gallbladder fasting volume (33.7 +/- 3.4 vs. 27.8 +/- 3.0 mL; P = 0.007) and residual volume (12.6 +/- 1.9 vs. 9.7 +/- 1.3 mL; P = 0.010) decreased, whereas the ejection fraction remained unchanged. However, gallbladder volume did not differ whether initial or recurrent stones were present. Gallbladder emptying was more impaired in patients with than patients without later recurrence (47% +/- 5% vs. 63% +/- 2%; P = 0.001). Cox analysis showed that gallbladder emptying was an independent determinant of the risk of gallstone recurrence (P = 0.002). Within 3 years, recurrent stones formed in 53% (actuarial analysis) of patients with an ejection fraction of < 60% but in only 13% of patients with an ejection fraction of > or = 60%. CONCLUSIONS: Gallbladder emptying is an important factor in the formation of recurrent gallstones.     

Choledocholithiasis and gallstone pancreatitis

Gallstones are commonly found within the main bile duct (MBD) of patients undergoing cholecystectomy. Retained MBD stones are a common cause of obstructive symptoms and complications. Endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy (ES) is the recommended modality for both the detection of such stones and their extraction. Recent trials of ERCP in conjunction with laparoscopic cholecystectomy suggest that it should be reserved for use post-operatively. Gallstones within the MBD are the most common single cause of acute pancreatitis. Initial treatment is supportive, although new agents designed to suppress the systemic inflammatory response are under development and have proved beneficial in clinical trials. Severe cases should be treated with systemic antibiotics and early removal of the obstructing stones by ERCP and ES. Prophylactic cholecystectomy is recommended to prevent further attacks of gallstone pancreatitis.     

Commentary: gallstone epidemiology

Distant metastasis occur in 10-20% of well differentiated thyroid carcinoma mostly in lung and bones. Radioactive Iodine is the gold-standard for treatment. However surgery should be advocated in bone solitary metastasis, with a curative or palliative approach as in vertebrae lesions. It improves quality of life. External radiotherapy alone or combined with radioactive Iodine is useful in selected cases. Results of chemotherapy are poor.     

Postoperative tetanus after gangrenous ileus

Tetanus has become an uncommon disease in developed countries. Tetanus is caused by exotoxins from the bacteria Clostridium tetani. This microbe, which is obligate anaerobe, is present in soil, and animal and human faeces. The condition usually appears after contamination of wounds. However, reports have been published of tetanus occurring after both acute and selective gastrointestinal surgery. We present a case of severe postoperative tetanus in a 57 year-old woman who underwent bowel resection after strangulation of the ileum. The patient was treated on an intensive care unit and was artificially ventilated for 64 days. Seven months later she had fully recovered. Clinical presentation, diagnosis, treatment, and complications are discussed in the report. The diagnosis of tetanus is made by clinical observation. Nowadays, lack of suspicion of this condition may cause delay in administering proper treatment. Women and older men are often inadequately immunized. Doctors should therefore examine the immunization status of these groups of patients regularly.