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Gallstone Ileus: a Review

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Gallstone Ileus: a Review BMJ Open Gastroenterol: first published as 10.1136/bmjgast-2019-000344 on 24 November 2019. Downloaded from Review Gallstone ileus: a review Koichi Inukai To cite: Inukai K. Gallstone ABSTRACT gallstone impaction. This paper describes a ileus: a review. BMJ Open Background Gallstone ileus is an important complication treatment approach for gallstone ileus based 2019;6:e000344. Gastro of cholecystolithiasis. In general, surgery is the treatment on findings of current reports. doi:10.1136/ of choice for such cases, but clinicians face difficulty in bmjgast-2019-000344 the selection of an appropriate approach. Closure of a cholecystoenteric fistula can be achieved through one- EPIDEMIOLOGY Received 28 September 2019 stage or two- stage operation. Two- stage operation has Revised 24 October 2019 Gallstone ileus occurs in 0.15%–1.5% of a lower mortality rate than a one- stage procedure, but Accepted 27 October 2019 cholelithiasis cases and <0.1% of ileus cases persistence of the cholecystoenteric fistula is associated 1 5 6 with the risk of carcinogenesis and recurrence of gallstone overall, and the recurrence rate is 5%–8%. ileus. Objective This study reviews the different surgical approaches according to the impaction site of the P ATHOGENESIS gallstone, using data of previous studies by our group and In patients with gallstone ileus, the gallstones clinical reports in the literature. are usually eliminated via an internal biliary Conclusions First, for cases involving impaction at the fistula. In majority of cases (75%–83%), the duodenum, the cholecystoenteric fistula can be repaired elimination route is from the gallbladder to in the same surgical field, and one-sta ge operation the duodenum. However, elimination may obtains favourable outcome; hence, one-sta ge operation proceed from the gallbladder to the colon is considered as treatment of choice. Second, for cases by copyright. or stomach, or in extremely rare cases, natu- involving impaction at the small intestine, natural closure of the cholecystoenteric fistula or low mortality is rally via the bile duct, involving passage from the gallbladder to the common bile duct and expected; hence, two- stage operation may be performed, 1 7 possibly using minimally invasive laparoscopy. Third, for subsequently to the papilla of Vater. Based cases involving impaction at the colon, natural closure of on these facts, this study focused only on the cholecystocolonic fistula is unlikely, and patients have internal biliary fistula classified as cholecys- a high risk of reflux cholangitis due to faecal fluid; hence, tointestinal fistula. In many cases, an internal one-sta ge operation is considered as treatment of choice. biliary fistula forms due to vascular insuffi- ciency or chronic inflammation caused by compression of the gallbladder wall during http://bmjopengastro.bmj.com/ calculus formation, which allows elimination INTRODUCTION of the calculus. Gallstone ileus is a relatively rare complication The most common impaction site of the gall- of cholelithiasis and a type of mechanical ileus stone is the ileum (50.0%–60.5%), jejunum involving impaction of gallstone in the intes- (16.1%–26.9%), duodenum (3.5%–14.6%) tinal tract.1 2 Owing to the high prevalence and colon (3.0%–4.1%), in order.8 9 Bouveret of gallstones, such cases may be presented in syndrome, named after the physician who routine medical practice, and clinicians should first discovered the condition, refers to impac- consider gallstone ileus in the differential diag- tion in the duodenal bulb that causes gastric nosis of acute abdomen. However, selection of outlet obstruction. The impacted gallstones appropriate treatment is difficult due to poor are mainly of the cholesterol type and approxi- on October 1, 2021 by guest. Protected © Author(s) (or their general condition of the patients with ileus, mately 4 cm in size, which is within the ≥2.5 cm employer(s)) 2019. Re- use and physicians need to make a decision on the range considered as impaction prone.10 permitted under CC BY- NC. No commercial re- use. See rights choice of immediate one-stage or two- stage and permissions. Published closure of the cholecystointestinal fistula or by BMJ. waiting for natural closure. DIAGNOSIS Department of Acute Care My previous studies reported the expe- Gallstone ileus has no distinctive symp- Surgery, Sakai City Medical rience with cases of gallstone ileus with toms, but tumbling gallstone advancement Center, Sakai, Osaka, Japan different sites of impaction, including the that results in alternating aggravation and 3 4 Correspondence to disease treatment. These studies indicate resolution of ileus is a relatively common 11 Dr Koichi Inukai; that in each patient, the choice of surgical feature. Many patients with gallstone ileus koichi. sums@ gmail. com approach should be based on the site of are elderly, present with comorbidities, have Inukai K. BMJ Open Gastro 2019;6:e000344. doi:10.1136/bmjgast-2019-000344 1 BMJ Open Gastroenterol: first published as 10.1136/bmjgast-2019-000344 on 24 November 2019. Downloaded from Open access poor general condition and delayed diagnosis that leads undetectable through radiography, and ileus due to malig- to dehydration, shock, sepsis, or peritonitis.12 nant tumour. In a review of 176 cases (49 male and 127 female patients; age, 24–91 years) of gallstone, Nakao et al5 TREATMENT reported abdominal pain at presentation in majority Principles of treatment of the patients (91.5%) with accompanied abdominal In general, since natural stone exclusion occurs at a low distension, vomiting and fever in 84.7%, 59.7% and rate of approximately 1.3%,9 surgery is indicated for cases 40.9% of all patients, respectively. of gallstone ileus involving both stone extraction to resolve In a review of 128 cases of Bouveret syndrome, Cappell 13 the ileus and closure of the fistula. However, whether and Davis reported the mean age of patients of 74.1 surgery should be performed as a one- stage or two- stage years, a larger proportion of female patients (female- to- operation remains unclear. Based on a study in 1994, male ratio of 1.86), and clinical symptoms of nausea and Reisner and Cohen9 indicated that despite mortality rate in vomiting (87%), abdominal pain (71%), haematemesis simple stone extraction of 11.7%, one- stage surgery shows (15%), weight loss (14%) and poor appetite (13%). higher mortality rate of 16.9% with a higher level of inva- In a systematic review of 38 cases of sigmoid gallstone siveness. Based on a study in 2014, Halabi et al1 reported ileus, Farkas et al14 reported the age range of patients of significantly increased length of hospital stay and mortality 65–94 years, mean age of 81.1 years, and nearly threefold rates in patients who underwent one-stage internal biliary higher proportion of female patients than of male patients; fistula closure; for patients with ileus, one- stage surgery is regarding clinical symptoms, 74% of the patients presented excessively invasive, and associated postoperative compli- abdominal pain, whereas 93% of the patients presented cations are common. Nevertheless, those studies assessed other obstructive symptoms of constipation (61%), overall cases of gallstone ileus regardless of the impaction vomiting (50%) and abdominal distension (26%). site, and majority of the cases included showed impaction Rigler et al15 reported that pneumobilia and intestinal at the small intestine. tract dilatation and specularity, calculus within the intes- With regard to two-stage surgery for gallstone ileus, the tinal tract, and calculus movement observed on plain initial procedure involves simple stone extraction, followed abdominal radiography are useful for diagnosis of the by fistula closure performed separately. However, two- stage by copyright. condition; however, the combined signs only appeared in surgery has a disadvantage of associated risk of recurrence, <50% of cases.5 9 retrograde cholecystitis, and cancer development due to In another review, Cappell and Davis13 reported the remaining cholecystointestinal fistula. Surgeons should frequency of the plain radiographic findings as follows: consider three related issues as follows. pneumobilia, 25%; gastric dilatation, 15%; calcified mass or calculus around the gallbladder or in the upper right Effects of persistent cholecystointestinal fistula abdominal area, 24%; moreover, those findings were Persistence of cholecystointestinal fistula is a potential confirmed on CT scans at frequency of 60%, 20% and causal factor for retrograde cholecystitis or gallbladder 90%, respectively, which indicates that advances in CT cancer. The cholecystointestinal fistula remained untreated could significantly improve the diagnosis rate. in 86.7% of cases of recurrent gallstone ileus, while chole- http://bmjopengastro.bmj.com/ The imaging findings of intestinal tract dilation showed cystectomy is necessary indication in patients with sympto- similar frequency in both abdominal radiography and CT matic gallstone. A total proportion of 11% of cholecystodu- (88% vs 92%); however, CT achieved more than twofold odenal fistula and 60% of cholecystocolonic fistula resulted higher rate of diagnosis of ectopic gallstone than radiog- in cholangitis,8 18 19 and 15% of cases of fistula showed 16 raphy (33% vs 81%), which suggests that CT is useful complication of gallbladder cancer.20 for visualisation of pneumobilia and intestinal calculi. Several case reports have indicated that contrast- Natural closure of cholecystointestinal fistula as a possible
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