Acute intestinal obstruction caused by impacted gallstones

ACUTE

INTESTINAL OBSTRUCTION CAUSED BY IMPACTED GALLSTONES WITH CASE REPORTS* LEWIS W. ANGLE, M.D. KANSAS

I

CITY,

NTESTINAL obstruction caused by the impaction of a Iarge gahstone in the Iumen is rather rare and warrants

KAN.

At St. Margaret’s Hospital in a series of 172 cases operated upon for intestinal obstruction there were onIy 2 due to im-

FIG. I.

Large, conica shaped stone from Case II, measuring 5 cm. in Iength and 3 cm. at its base. Note pointed projection on superior border which caused perforation 49 inches distal to fi.stuIous opening in gaI1 bIadder which is shown in Figure 3.

special interest, in that an earIy diagnosis and earIy operation wiI1 markedIy decrease the mortaIity rate. A review of the Iiterature shows the first recorded case was that of BarthoIinl in 1654. Later in 18go Courvoisier2 anaIyzed a11 reported cases prior to that date and found 131. In rgr4 Wagner3 made an exhaustive study of the Iiterature and found 334 cases causing obstruction. From the British MedicaI Association4 a survey of 3064 cases of intestina1 obstruction reported from seven hospitals in 1923, impacted gaIIstone was the cause in only 28 cases or Iess than I per cent, the most frequent being hernia, intussusception, maIignancy, adhesions, voIvuIus and interna StranguIation.

FIG. 2. Large single stone from Case I, measuring 7 cm. in length and from 2.5 to 3.5 cm. in diameter, which completely occluded lumen of gut.

pacted gaIlstones. Powers5 found 4 cases in 179 cases of intestina1 obstruction. Moore6 states from a11 avaiIabIe statistics that gahstones cause from 1 to 2 per cent of a11 intestina1 obstruction. Martin’ reports I case out of 280 cases of intestinal obstruction. So a11 statistics seem to be within a norma limit except the earlier views of Courvoisier, who gave a much higher estimate. The recent Iiterature incIudes onIy 3 cases which have been reported, one by Jackson and EweI18 and two by Siewerth.g GaIlstones entering the intestina1 tract usuaIly admit themseIves by one of two methods: (I) by perforation from the gaI1 bIadder through the duodenal waI1, of (2) by entering through the common duct. Our 2 cases chose the first route, by first producing a ChoIecystitis and ChoIeIithiasis

* Read before the Kansas City Southwest ClinicaI Society,

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foIIowed by mceration, erosion and pericholangitis. This was foIlowed by the formation of adhesions between the gaII bIadder and neighboring viscera, and perforation occurring within these adhesions. The duration of and the presence of symptoms seems to be questionable from recorded reports. Reimann and BloomlO reported a case foIlowing autopsy finding, the patient having died of empyema fohowing Iobar pneumonia. The postmortem examination presented a biliary fistuIa between the gall bladder and the pyloric portion of the stomach. A caIcuIus about 2 cm. in diameter was found in a cystic cavity within the stomach wall. Though this patient was jaundiced there was no other history of galI-bladder disease. According to the history of both of our cases, they reIate the presence of a sudden sharp pain in the region of the gaI1 bIadder, which was foIlowed by continued nausea and vomiting. Previous to this attack they gave a history referable to galI-bIadder disease. Neither of our patients was jaundiced due to the fact that the stone perforated through the wall of the gall bIadder at the fundus into the duodenum at about the middle third. The extent of passage down the intestina1 tract is variabIe anywhere from the point of entrance to an exit at the rectum. Murphy” states that, of 125 cases, 70 after various and repeated coIics, emesis, peritonitis, ireus, etc., were cured spontaneously by the passage of the stones per rectum. In such cases they may be singIe or muItiple stones, usuaIIy of smaI1 caliber. Both of our cases were singIe, Iarge stones. In Case I the stone lodged 3$$ feet from the adhesions of the gaI1 bladder to the duodenum. In Case II the stone Iodged 49 inches from the adhesions of the gall bladder to the duodenum. Once the diagnosis of obstruction due to impacted gallstones is made, immediate operation is imperative, and the duration as brief as possible. In the majority of cases a simpIe enterostomy is sufficient, and it is our beIief that a choIecystectomy shouId not be considered unti1 a later date. The best

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method of cIosing the enterostomy seems questionabIe. Brown’2 advocates recovering the stone through a transverse incision

FIG. 3. Specimen en masse from Case 1~. Liver is sectioned, with probe passing through fistulous tract from gaI1 bIadder into duodenum. In Iowcr Ieft corner we see stone (Fig. I) has ruptured through gut wall, presenting pointed projection.

in order to avoid such constriction of the intestina1 lumen as occurs when a Iongitudinal incision is cIosed and inverted. Davis13 advises a transverse closure of a 1ongitudinaI incision. In Case I we made a IongitudinaI cIosure of a IongitudinaI incision. CASE I. Mrs. L. D., white female, aged fifty-six, entered St. Margaret’s Hospital on 31, 1930 with a chief compIaint of December vomiting. Present Illness: About one year ago patient had an attack of vomiting with pain in the right side aIong the Costa1 margin. This pain was associated with much gas. During this sickness she was admitted to a diagnostic clinic, leaving much improved, with the diagnosis of gaII-bladder disease. The patient enjoyed verv good health until Christmas day, when foIIo&ng dinner she began to vomit.

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She had no definite pain, but a generahzed abdomina1 discomfort, and was unabIe to retain any food or Iiquid on entering the hospita1. Patient denies a history of ever having been jaundiced. She has no substerna burning foIIowing vomiting. BoweI movements have been very irregular, being forced by enemas. She has voided onIy smaI1 amounts of urine. The patient has Iost no weight in past three years. Her history is otherwise negative. Physical examination reveaIs a Iarge woman, weighing 155 pounds, good nutrition, skin very dry, no edema, no jaundice, and no genera1 gIanduIar enIargement, thyroid not enIarged, joints negative, extremities negative and examination of heart and Iungs negative. Daily reports on the patient are as foIIows: December 31, 1930: hypodermocIysis of 5 per cent gIucose in zooo c. c. of saIine. Einhorn tube inserted with gastric Iavage every two hours. BIood count: red bIood ceIIs 6,270,ooo; white bIood ceIIs 21,350; poIymorphonucIears 83 per cent, hemogIobin go per cent. BIood chemistry: nitrogen sugar 206, non-protein I 17.6, urea nitrogen 9.4, creatinine 3.2, carbon dioxide combining power 57.4, caIcium I 1.5 and phosphorus 4.2. January I, 1931: UrinaIysis (catheter specimen) : specific gravity I .o IO, aIkaIine reaction, negative for aIbumin and sugar, few red bIood ceIIs and 3 plus white bIood ceIIs. Vomiting continued. Two thousand cubic centimeters of saIine with 5 per cent gIucose were given by hypodermoclysis. Acriffavine, grains x t. i. d. January 2, 1931: 2000 c. c. of 2 per cent gIucose given by hypodermocIysis; 2000 c. c. norma saIine given by hypodermocIysis. Patient showed some improvement. Vomiting is decreasing. January 3, 1931: 2000 c. c. of 2 per cent gIucose given by hypodermocIysis; 2000 c. c. of saIine given by hypodermocIysis. BIood chemistry: sugar 135, non-protein nitrogen 53.1, urea nitrogen 6.7, creatinine I. I, carbon dioxide combining power 70, amino acids 6.2 mg. January 5, 1931: Patient is some better. Feces examination shows some fat gIobuIes. Chemistry examination: amino acids 5.2 mg. January 4, 1931: 4000 c. c. of norma saIine given by hypodermocIysis. Patient’s condition unchanged. January 6, 193 I : Patient is much better. January 7, 1931: Liver function test five minutes 45 per cent, thirty minutes 5 per cent.

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January 8, 1931: Urine is negative. BIood cuIture: no growth in four days. Patient is much better. January g, 193 I : Patient is greatIy improved. January I I, 193 I : Patient is much improved. January 14, 193I : X-ray gaII-bIadder visuaIization with tetva iodide. Report is as foIIows: “The radiographs taken tweIve and fourteen hours fai1 to show a shadow of the gaI1 bIadder. There is a pecuIiar rounded shadow occupying an abnorma1 axis for the gaI1 bIadder, but which suggests in its detai1 caIc&cation of the waI1 of a Iarge gaI1 bIadder. This shadow’s identity is questionabIe.” January 15, 193 I : Patient’s condition exceIIent. January 18, 1931: Patient is discharged. Patient was readmitted to St. Margaret’s HospitaI on January 29, 1931, compIaining of vomiting which began on the night of January 28 and continued throughout the night. The vomitus on admission to the hospita1 was biIe stained. Two thousand cubic centimeters of norma saIine were given by hypodermocIysis. January 30, 193 I : UrinaIysis negative. Two thousand cubic centimeters of normaI saIine given by hypodermocIysis. January 31, 1931: Patient is much better. February I, 1931: Patient is much better. Two thousand cubic centimeters of norma saIine given by hypodermocIysis. February 3, I 93 I :X-ray examination. Patient is seen without a preIiminary mea1, and is able to take onIy a smaI1 amount of opaque media. First boIus is projected into the duodenum, visuaIizing a Iarge trianguIar duodena1 bulb. In the semirecumbent position the media gravitates to the right of the spina prominence and the upper jejunum fiIIs rapidly. Definite diIatation of the upper jejunum is apparent and regurgitation is observed. The appearance of the jejunum does not suggest an absoIute obstruction. PIates : “FiIms of the abdomen show an incompIete obstruction of the jejunum on the Ieft side of the abdomen.” February 4, 1931: 2000 c. c. of norma saIine given by hypodermocIysis; 2000 c. c. of 5 per cent saIine with 2 per cent gIucose given by hypodermocIysis and two 50 c. c. ampuIes of 50 per cent gIucose given intravenously. At no time through the stay in the hospita1 was visible peristaIsis noted.

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February 5, 1931: Patient was operated upon. A preoperative diagnosis was made of high intestinal obstruction due to impacted gallstone. Operation was as foIIows: Under amytal, novocaine and ether anesthesia, a supraumbilical midline incision was made. On opening the peritoneum a Iarge amount of bile-tinged fluid was found, and a markedIy diIated smaI1 intestine. The stomach and pancreas reveaIed nothing abnorma1 on examination. The smal1 intestine which presented itseIf into the wound was distended and engorged. On tracing the distention there was found a collapsed portion about the dista1 portion of the jejunum and on paIpation there was found to be a hard mass about the shape and size of a duck egg, compIeteIy obstructing the lumen of the gut. The gut dista1 to the mass was coIIapsed. IntestinaI cIamps were appIied distal and proxima1 to the mass and a Iongitudina1 incision about 5 cm. in Iength was made opposite the mesentery. The mass was easiIy delivered, and thereby exposed the intestina1 mucosa, which from its condition showed that the stone has been in its present position sometime. But the condition (Fig. 2) of the gut did not warrant a resection. The incision was closed with catgut IongitudinaIIy. The gaI1 bladder was not explored. The wound was cIosed in Iayers without drain and patient returned to her room in good condition. February 6, 1931: 4000 c. c. saIine was given by hypodermocIysis. February g, 193 I: Patient’s postoperative convalescence is excellent. Abdomen is soft and in excellent condition. February IO, 1931: At I ~30 P.M. patient was awakened by a very sharp, severe pain in the Iower abdomen. She was perspiring and Iooked as though she were in great pain. The abdomen was soft, no rigidity, but there was tenderness on firm pressure. The abdomen is tympanic, but no marked distention. At 2~00 P.M. the patient began having chiIIs. Pain became more severe and abdomina1 rigidity was present. With a diagnosis of intestina1 perforation the abdomen was reopened. Operation: The original surgica1 wound \vas reopened. The coils of the jejunum presented themseIves and were distended. No exudate n-as visibIe. On examination of the galI-bladder region and the under surface of the liver, a Iarge amount of seropurulent fluid was present

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with an abundance of pIastic exudate. The gaII-bIadder waI1 was injected and thickened, with many adhesions between it and the duodenum. A drain was pIaced under the Iiver and stab drain pIaced in the peIvis. The peIvic wound was cIosed, and the patient taken to her room in poor condition. Her condition grew rapidIy worse and the patient died at 9~00 P.M. the same day. Autops~i findings were as foIIows: (Only the organs of interest wiI1 be noted). The peritoneal cavity contained about 1500 c. c. of purulent fluid which contained abundant fibrin. Just beIow the surgica1 incision there is a part of the jejunum upon which an enterostomy flas been performed. Three and one-haIf feet from the adhesions of the gaI1 bIadder to the duodenum there is an opening through which the intestina1 contents have access to the peritoneal. cavity. The gall bIadder appears connected to the duodenum. The adhesions between the gaI1 bIadder and the duodenum upon dissection revealed a smaI1 fistulous tract present between the gall bIadder and the duodenum, measuring about 5 mm. in diameter. The gaII-bladder wall is markedIy thickened. No stones are present. CASE II. Mrs. M. T. was admitted to St. Margaret’s HospitaI on March 31, 1931. She is a coIored femaIe, aged fifty-eight. Chief compIaint is pain and vomiting. Present iIlness dates back to about four weeks ago, when the patient had been having a duI1 pain in the epigastrium. One night whiIe asIeep she was suddenI? awakened b)- a sharp pain in the epigastrmm which was foIIowed by vomiting, and continued unti1 admission to the hospital. Patient has been unabIe to retain any food and only a small amount of Iiquids. Patient describes the vomitus as being of dark bro\vn color and containing blood. The stooIs were tannish in coIor. She has Iost an appreciabre amount of weight in the past month. Due to the physica condition of the patient a-e were unable to obtain more history. PhJ.sical examination reveaIed an cstremeIy thin colored woman with an essentiaIIy negative examination, except for the abdomen which was fuII. No ascites. Pain was diffuse but most marked in the upper quadrant. No masses were felt. Liver and spleen were not palpable due to extreme tenderness. Da& reports on the patient are as foIIows: Vomitus benzidine test hIarch 31, 1931:

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positive for bIood. Red bIood ceIIs ~,~OO,OOO, or death, or they may be passed by rectum hemogIobin 70 per cent, white bIood ceIIs 9150, without symptoms. poIymorphonuc1ear.s 75 per cent. Urine was Our first case was obviousIy a case of e.ssentiaIIy negative. Three thousand cubic intestina1 obstruction, the perforation from centimeters of saIine was given by hypoderthe gaII bIadder into the duodenum occurmocIysis; 30 c. c. of 40 per cent gIucose was ring about one year before admission into given intravenousIy. the hospita1. In Case II the entrance ApriI I, 1931: 3000 c. c. of saIine was given of the gaIIstone into the intestina1 tract by hypodermocIysis, 50 c. c. of 50 per cent was four weeks before admission to the gIucose given daily. hospita1. The perforation of the intestine, ApriI 2, 1931: Patient’s condition does not resuIting in peritonitis, occurred at night improve and does not warrant an expIoratory Iaparotomy. during sIeep and the day before entering April 4, rg3I : Patient is growing weaker the hospita1. There was a fleeting obstrucwith increasing pain. She is coId and cIammy tion for four weeks. There was no history and has sIight distention. of gaII-bIadder disease which aided in April 5, 1931: Patient died at 3:0o A.M. making the diagnosis of obstruction due Autopsy findings were as foIIows: Upon to gaIIstones. opening the peritonea1 cavity the peritoneum Acute intestinal obstruction caused by contained a Iarge amount of GbropuruIent impacted gaIIstones is more infrequent exudate as we11 as some Iiquid feca1 materia1. than one wouId judge before reviewing the About 2000 c. c. of fluid are present in the literature. peritonea1 cavity, so that the surface of the RegardIess of the mode of entrance peritoneum both in the Iesser and greater peritonea1 cavities is covered with a fibrointo the intestina1 tract, the symptoms puruIent exudate, and numerous areas of are essentiaIIy the same except the preshemorrhage are present, especiaIIy in the ence or absence of jaundice. The duration Iesser peritonea1 cavity over the pancreatic of time up to a partia1 or complete obstrucregion. It is noted that the entire transverse tion is a variabIe factor. In our first case coIon is adherent to the gaI1 bIadder region. the time was one year and the second was The Iiver over the gaI1 bIadder appears rather firm. The gaII-bIadder waI1 is markedIy con- four months. Once the diagnosis is made an earIy operation is imperative, the extracted and upon remova of the ffuid from the to the peritonea1 cavity there is seen a perforation in tent of which varies according of the patient, and regardIess the smaI1 intestine (Fig. 3) about the Iower condition portion of the jejunum which contains a Iarge of the severity of the condition of the pastone. The gastrointestina1 tract shows a tient, preoperative and postoperative adfistulous opening in the duodenum and a Iarge ministration of saIine shouId be given stone, rather cone shaped, with the smooth subcutaneousIy and intravenousIy. portion pointing upwards. About the base the Case I was entered at St. Margaret’s stone appears rather rough and irregular; HospitaI on the surgica1 service of Dr. the intestine around the stone has become C. C. NesseIrode and Case II on the surgica1 necrotic and is ruptured. The stone presented service of Dr. M. J. Owens. itseIf about 49 inches distal to the fistuIous opening of the gaI1 bIadder into the duodenum. At this point the waI1 is very thin and the erosion measures 2.5 by 1.5 cm. COMMENTS

The presence of a gaIIstone or stones in the intestinal tract without the presence of symptoms is an estabIished fact, in that they may lie ddrmant for a Iong period of time and never cause symptoms

LITERATURE I. BARTHOLIN. Quoted by Martin.7 2. COURVOISIER. Cavistisch-Statistishe

Beitrage zur PathoIogie und Chirurgie der GaIIenwege. Leipzig, I 890. 1. WAGNER. A. IIIeus durch GaIIensteine. Deutscb. Ztscbr.‘j. Cbir., 130: 353, 1914. 4. Report from annua1 meeting of the British MedicaI Association. Brit. M. J., 2: 993, 1925. [For Remainder of Literature see p. 412.1