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Abdominal Pain and Vomiting in an Elderly Diabetic Woman Proptosis In 712 Postgrad Med J 2003;79:712–714 mechanical obstruction that might require Postgrad Med J: first published as 10.1136/pgmj.2002.004127a on 5 January 2004. Downloaded from SELF ASSESSMENT ANSWERS urgent enterolithotomy.4 The recurrence rate of gall stone ileus is less than 2%.2 Abdominal pain and vomiting Clinical features Usually abdominal pain is a prominent Final diagnosis in an elderly diabetic woman symptom, and associated illnesses such as diabetes and cardiovascular disease are com- Gall stone ileus. Q1: What abnormalities are seen on mon. It causes signs of small bowel obstruc- the plain film (fig 1; see p 709) and References tion like nausea, vomiting, abdominal 1 Foss HL, Summers JD. Intestinal obstruction from computed tomogram (fig 2; see p 709) distension, and absence of bowel sounds in gall stones. Ann Surg 1942;115:721–35. of the abdomen? cases of complete obstruction. Signs of 2 Reisner RM, Cohen JR. Gallstone ileus: a review Plain film shows air in the biliary tract and intestinal obstruction are seen mostly if the of 1001 reported cases. Am Surg gall bladder, dilated loops of small intestine, gall stone impacts at the ileocaecal junction. 1994;60:441–6. and multiple air-fluid levels in small bowel However, the characteristic features of intest- 3 Clavien PA, Richon J, Burgan S, et al. Gallstone loops. The computed tomogram shows large inal obstruction are found in only 50% to 70% ileus. Br J Surg 1990;77:737–42. of patients.23This may be because as the gall 4 Williams IM, Hughes ODM, Hicks E, et al. Gall gall stone impacted in jejunum and multiple stone ileus following multiple endoscopic air-fluid levels in small intestine. stone ‘‘tumbles’’ through the gastrointestinal retrograde cholangiopancreatographies. J R Coll tract, it impacts and disimpacts, producing Surg Edinb 1997;42:423–4. Q2: What is the diagnosis? intermittent mechanical obstruction. 5 Deitz DM, Standage BA, Pinson PW, et al. Gall stone ileus. Improving the outcome in gallstone ileus. Am J Surg 1986;151:572–6. Q3: What other variants of this disease Investigations 6 Rodriguez-Sanjuan JC, Casado F, Fernandez MJ, The diagnosis of gall stone ileus is often are known to occur? et al. Cholecystectomy and fistula closure versus difficult to make. enterolithotomy alone in gallstone ileus. Br J Surg The complications of cholelithiasis are shown The classic radiographic signs of gall stone 1997;84:634–7. in table 1. Gall stones can get impacted at ileus on abdominal plain film are pneumobi- various sites, the commonest being the lia, mechanical small bowel obstruction, and ileocaecal junction. The other described sites the presence of a new stone or changed of gall stone impaction with in the bowel are position of a previously identified stone, Proptosis in an asthmatic the jejunum, stomach, colon, duodenum, and known as Rigler’s triad.1 patient pylorus (Bouveret’s syndrome). Ultrasound reveals diseased gall bladder, GALL STONE ILEUS whether there is gas in it or in the bile ducts Q1: What is the diagnosis of this or both, and fluid filled bowels that can be respiratory condition? Gall stone ileus is a mechanical bowel followed to the stone in the intestine. The obstruction caused by passage of gall stones presence of stones in the gall bladder will The diagnosis in this case is allergic broncho- from the biliary system through a biliary- modify the planned operative procedure in pulmonary aspergillosis (ABPA). ABPA occurs enteric fistula with impaction within lumen the treatment of gall stone ileus. in 6%–20% of individuals with asthma and of the bowel. approximately 10% of individuals with cystic The characteristic features of Rigler’s triad 1 It is an uncommon complication of biliary are easily identified on computed tomogra- fibrosis. It is characterised by repeated stone disease, accounting for only 2% of all phy even if abdominal plain film is subtle. episodes of exacerbations interspersed with cases of intestinal obstruction. Gall stone Even if abdominal radiography reveals the periods of remissions. Diagnostic criteria ileus is, however, more common in the characteristic signs of small bowel obstruc- include (1) asthma, (2) fleeting pulmonary elderly and accounts for approximately 25% tion, computed tomography is useful for opacities on chest radiographs, (3) positive of all cases of intestinal obstruction in skin tests for Aspergillus fumigatus, (4) periph- 1 excluding complications (for example, stran- patients over 65 years of age. gulation). When unexplained bowel obstruc- eral blood eosinophilia, (5) precipitating The gall stone that causes ileus is usually tion is present, particularly in the elderly, the antibodies to A fumigatus, (6) raised serum more than 2.5 cm in diameter. Multiple IgE levels, and (7) central bronchiectasis.2 12 early use of computed tomography is strongly stones are present in 3%–15% of cases. recommended. Other minor criteria include expectoration Gall stones usually enter the intestinal Endoscopy has been the main diagnostic of golden brown sputum plugs, positive http://pmj.bmj.com/ lumen through a cholecystoenteric fistula, procedure for Bouveret’s syndrome. The sputum culture for aspergillus species and and 68% of these are between the gall bladder diagnosis was made endoscopically in more late (Arthus-type) skin reactivity to A and the duodenum. A history of prior biliary than 90% of the cases.4 fumigatus. tract disease is present in almost 50%–60% of If the disease is not diagnosed early and patients with gall stone ileus.2 treated adequately, lung damage continues The most frequent site of stone impaction Treatment to progress silently leading to fibrosis in is the ileum (.60% of cases), as it is the Gall stone ileus is a serious geriatric surgical the upper lobes.3 The upper lobe fibrosis of narrowest part of the bowel. Other sites of emergency. It has a high morbidity (15%– ABPA can mimic pulmonary tuberculosis obstruction are the jejunum (16%), stomach 18%) and mortality (17%). and patients are often unnecessarily on October 1, 2021 by guest. Protected copyright. (14%), colon (4%), and duodenum (3%). The management of gall stone ileus is treated with antituberculosis therapy as in Gastric outlet obstruction, or Bouveret’s controversial. The choice is between perform- our case. syndrome, occurs when the gall stone lodges ing simple enterolithotomy or a single stage in the duodenal bulb (1%).1 procedure involving enterolithotomy, chole- Q2: Which respiratory diseases have cystectomy, and fistula closure. Current coexistent sinus and orbital reports favour enterolithotomy only, with involvement and what was the cause in definitive biliary surgery performed later if Table 1 Complications of this patient? cholelithiasis symptoms persist. Advocates of the combined procedure contend that it prevents recurrent Allergic and granulomatous diseases com- gall stone ileus, cholangitis, and gall bladder monly involve the lung, sinuses, and the orbit Complication Percent 4 carcinoma complications that occur in nearly (box 1). The diagnosis in this condition was Biliary colic 70–80 one third of patients who undergo entero- allergic fungal sinusitis with orbital aspergil- Acute cholecystitis 10 lithotomy only. Simple enterolithotomy car- losis in a patient with allergic bronchopul- Emphysematous cholecystitis ,1 ries a mortality of 11.7% compared with monary aspergillosis. Mirizzi’s syndrome ,1 16.9% for one stage procedure. The most Hydrops of the gall bladder ,1 common source of operative morbidity is Q3: What is the significance of C-ANCA Small bowel obstruction 1 wound infection, occurring in 30%–40% of in chronic lower respiratory tract (gall stone ileus) cases.56 infections? , Perforation of gall bladder 1 In duodenal stone impaction extracorpor- Positive C-ANCA is characteristic of Acute biliary pancreatitis 12 eal shock wave lithotripsy is successful in Wegener’s granulomatosis. However, in a Acute suppurative/obstructive – cholangitis fragmenting the stone. Endoscopic stone study done by Ohno et al raised myeloper- removal is especially indicated in poor risk oxidase ANCA and bactericidal/permeability patients. A dislodged impacted stone can increasing protein ANCA levels were found migrate distally and cause small bowel in patients with chronic lower respiratory www.postgradmedj.com Self assessment answers 713 controlling local inflammation. It is also degenerative changes are seen at the C5–C6 Postgrad Med J: first published as 10.1136/pgmj.2002.004127a on 5 January 2004. Downloaded from Box 1: Allergic and granulomatous recommended that systemic antifungals be intervertebral disc space. diseases used to prevent progression to invasive forms of fungal sinusitis. Intravenous amphoteri- Q2: What abnormalities are seen on cin-B has been found to be more beneficial the MRI scan (p 711)? than the less toxic agents of the azoles group N Allergic group: Sagittal T2 weighted MRI scan of the cervical in view of the poor in vitro activity of these spine shows narrowing of the bony spinal – ABPA. agents.6 canal at the arch of C1 vertebra. This in turn N In conclusion, patients with ABPA should Granulomatous group: gives rise to generalised narrowing and be evaluated for the presence of coexistent distortion of the spinal cord at the cranio- – Classical Wegener’s granulomato- allergic fungal sinusitis and orbital aspergil- medullary junction. There is some signal sis. losis to avoid further complications. change within the cord itself at this level. – Necrotising sarcoid granulomas. Final diagnosis – Behc¸ets disease. Q3: What is the likely diagnosis? Allergic fungal sinusitis with orbital aspergil- – Midline granulomas. losis in a patient with allergic bronchopul- Anterior atlantoaxial subluxation involving supra-axial spine. – Polyarteritis nodosa. monary aspergillosis. – Churg-Strauss syndrome. Q4: How can this condition be treated? – Relapsing polychondritis. References Atlantoaxial subluxation, when symptomatic 1 Slavin R, Stanevyak D, Lonigro A, et al. Allergic – Benign lymphocytic angitis. or is severe, can be treated by posterior bronchopulmonary aspergillosis: a North cervical fusion with or without stabilisation – Nasopharyngeal lymphomas with American rarity.
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