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Gallstone Ileus
Symposium on Surgery in the Medically Compromised Patient
Gallstone Ileus Samuel B. VanLandingham, M. D.,* and Charles William Broders, M.D. t
Gallstone ileus, first described by Bartholin in 1654, is mechanical intestinal obstruction caused by· impaction of one or more gallstones within the lumen of the bowel. Courvoisier reported 131 cases of gallstone ileus in 1890 with a mortality of 44 per cent in the 125 surgical operations performed for the condition. 7 Gallstone ileus is sufficiently uncommon that most surgeons have only a very limited experience with it. The incidence of small bowel obstruction due to gallstones is reported to be between 1 and 3 per cent.I8 This increases to 25 per cent in patients aged 65 years or older.13 Raiford states that the average general surgeon can expect to encounter 1 case of gallstone ileus in every 300 cases of cholelithiasis and in every35 cases of intestinal obstruction. 13 Few surgical patients are as compromised medically as is the patient with gallstone ileus. Typically, gallstone ileus occurs in the sixth or seventh decade of life, an age at which there are often various other medical illnesses. In their series, Day and Marks 8 reported serious concomitant disease in 79 per cent of patients with gallstone ileus: diabetes mellitus in 50 per cent; major cardiovascular disease in 58 per cent; and major obesity in 58 per cent. For these reasons, gallstone ileus carries five times the mortality of any other nonmalignant cause of small bowel obstruction. ll
PATHOGENESIS Gallstone ileus is preceded by an initial episode of acute cholecystitis. Inflammation then develops in the tissues surrounding the gallbladder and adhesions form between the gallbladder and the intestine. The offending gallstone gradually erodes through the joined walls of the gallbladder and bowel to form a cholecystoenteric fistula through which the stone passes. In most cases, the fistula is located between the gallbladder and the duodenum, although other sites may be involved. Wakefield, Vickers, and Walters 19 from the Mayo Clinic reported that among 176 fistulas, the site of per'Resident, General Surgery, Scott and White Memorial Hospital, Temple, Texas tProfessor, Department of Surgery, Texas A. and M. University College of Medicine; Division of General Surgery, Scott and White Clinic, Temple, Texas
Surgical Clinics of North America-VoL 62, No.2, April 1982
241
242
SAMUEL B. VANLANDINGHAM AND CHARLES WILLIAM BRODERS
foration involved the duodenum in 101 cases, the colon in 33, the stomach in 7, and multiple sites in 11. Once within the intestinal tract, the gallstone may be vomited, it may pass spontaneously through the rectum, or it may become impacted and cause obstruction. Most reports indicate that stones smaller than 2.5 cm pass through the gastrointestinal tract spontaneously and are excreted uneventfully in the stools. lO Stones as large as 5 cm in diameter have passed spontaneously. J. A. Bargren in a personal communication to one of the authors (C. W. B.) stated that he plucked a gallstone from the rectum of a patient who had had intestinal obstruction that resolved itself with the passage of the stone down to the rectum. The largest gallstone causing intestinal obstruction measured 17.7 cm in its largest diameter and was removed from the transverse colonY The largest stone in our series measured 8 cm in greatest diameter, and the smallest measured only 2.3 cm in largest diameter. The site of obstruction is usually in the terminal ileum, the narrowest portion of the small bowe1. 9 In addition, there is some evidence to suggest that peristalsis is weaker here than it is in the more proximal intestine. 12 In our series of nine patients, the obstructing stone was located in the ileum in seven, in the proximal jejunum in one, and in the duodenum in one (Fig. 1).
Figure 1. Examination of the upper gastrointestinal tract demonstrates a large filling defect in the duodenum. Superimposed on the x-ray film is the actual gallstone extracted from the duodenum at laparotomy.
r
243
GALLSTONE ILEUS
DIAGNOSIS The diagnosis of gallstone ileus is quite difficult to make preoperatively. In a large series, the correct preoperative diagnosis was made in only four (33 per cent) of cases, with a resulting delay from the time of admission to the time of operation of two to three days on the average. Symptoms are often intermittent, as the obstructing gallstone can lodge at various levels in the bowel as it passes distally, giving incomplete small bowel obstruction. This is referred to as the "tumbling" phenomenon, indicating that the stone tumbles through the intestinal tract, causing either a transient complete or partial obstruction at various levels of the bowel. As each attack clears, the patient may feel much improved and may delay seeking medical attention, or upon seeking medical attention, the physician may be lulled into making a diagnosis of subsiding gastroenteritis. This delay in diagnosis and early surgical intervention adds to the morbidity and mortality of the disease. 8 Physical examination reveals only those findings characteristic of mechanical bowel obstruction. The patients are often acutely ill, dehydrated, and distended with high-pitched bowel sounds and tender abdomens. Laboratory studies are usually not specific but reflect deydration and electrolyte imbalance. Abdominal plain films are of major importance in establishing a diagnosis. Four of the nine patients in our series had positive plain film examinations suggestive of gallstone ileus. In 1941, Rigler, Borman, and Noble l4 described four roentgenographic signs in gallstone ileus, (1) air in the biliary tree, (2) radiographic evidence of partial or complete intestinal obstruction, (3) direct or indirect visualization of the obstructing stone by means of contrast medium in the intestine, and (4) change in the position of a previously observed stone. It should be noted that the presence of air in the biliary tree is not unique to gallstone ileus. Sedlock and others, reviewing 74 instances of pneumobilia in a Mayo Clinic study, found that 44 cases were due to previous surgical procedures of the biliary tract,16 These authors stress that an incompetent sphincter of Oddi can also permit the chronic reflux of gas into the biliary radicals. However, the presence of pneumobilia associated with the signs and symptoms of intestinal obstruction certainly strongly suggests gallstone ileus. 2
TREATMENT Operation is mandatory in the proper treatment of gallstone ileus. Delaying surgical intervention in the fond hope that the stone will pass spontaneously or that intestinal tube decompression will suffice are to be condemned. Balch reported an 87 per cent mortality rate in patients operated on with gallstone ileus who had symptoms longer than 72 hours' duration as opposed to a 45 per cent mortality rate when the symptoms were less than 72 hours' duration. l A short delay for hydrating the patient and correcting imbalance preoperatively is often necessary. These elderly individuals are
244
SAMUEL B. VANLANDINGHAM AND CHARLES WILLIAM BRODERS
often physiologically fragile and require close attention to their fluid and electrolyte disturbances, the control of their diabetes, infection, and other complicating conditions. The Swan-Ganz catheter is often an indispensable aid in monitoring fluid balance in these patients. The prime objective of all operations for gallstone ileus is to relieve the obstruction. In this regard, most authorities recommend enterolithotomy alone as the treatment of choice.l· 16 After identifying the offending stone, it is desirable to milk the stone proximally into uninvolved intestine. A longitudinal enterotomy incision is then performed and the stone is extracted. The enterotomy is then closed in a transverse fashion. If the stone is impacted in the intestine and cannot be easily milked retrograde into healthy tissue, a segmental bowel resection may be required. It is essential to examine the bowel, both small intestine and colon, for additional stones, since a 5 per cent reobstruction rate secondary to retained stones has been reported. 5 One must also examine the gallbladder and the cholecystoenteric fistula for evidence of leakage, abscess, or impending gangrene, as well as for additional stones. In recent years, many surgeons have advocated the one-stage repair for gallstone ileus in which cholecystectomy and repair of the cholecystoenteric fistula are combined with enterolithotomy.6. 10.20 This policy is supported by the increased risk of carcinoma of the gallbladder in patients with cholecystoenteric fistulas 4 and by a 30 per cent incidence of recurrent pain postoperatively in patients treated by enterolithotomy alone.20 Proponents of this approach stress careful selection of patients, since some are so severely debilitated that they will not tolerate prolonged surgical procedures. A review of the literature since the one-stage repair was introduced shows no significant increase in morbidity or mortality with the one-stage repair as opposed to enterolithotomy alone (Table 1). It is important to stress that the one-stage repair should only be performed under optimal conditions as far as the general condition of the patient and the associated pathologic findings are concerned. When the patient is too ill or the dissection required is too fraught with hazard, only relief of the obstruction itself should be performed. Upper gastrointestinal tract and biliary tract studies should be planned for the postoperative period in patients treated by enterolithotomy alone. A demonstration of cholelithiasis with or without symptoms postoperatively indicates the need for further surgical treatment, that is, cholecystectomy. Prior to 1925, the mortality rate due to gallstone ileus was a little over 60 per cent. But this figure has been reduced to less than 15 per cent in most Table 1.
Comparison of Mortality in Enterolithotomy and One-Stage Repair for Gallstone Ileus
Enterolithotomy One-stage repair TOTAL
*Average
NUMBER OF CASES
NUMBER OF DEATHS
156 35 191
17 7 24
% DEATHS 11
20 13*
T
245
GALLSTONE ILEUS
current series. Morbidity remains high, however, in that almost 75 per cent of patients undergoing surgical procedures for correction of gallstone ileus had significant wound infections postoperatively. Berliner and Burson reported a 15 per cent incidence of carcinoma of the gallbladder in patients with cholecystoenteric fistulas as compared with an incidence of only 0.8 per cent in patients with cholecystectomies performed for all other reasons. 3
SCOTT AND WHITE EXPERIENCE The hosptial records of nine consecutive cases of gallstone ileus occurring from 1954 to 1977 were reviewed. All nine patients had a diagnosis documented at laparotomy (Table 2). All nine of the subjects were females. The age of patients in the series ranged from 53 to 91 years, with a mean age of 75.4. All patients presented with abdominal pain, nausea, and vomiting. Other common presenting complaints were obstipation and abdominal distention. Arteriosclerotic heart disease, diabetes mellitus, and hypertension were frequent concomitant medical illnesses., Table 2.
Findings in Nine Patients with Gallstone Ileus Treated at the Scott and White Clinic POSITIVE
PATIENT
HISTORY OF
X-RAY
CIIOLELITIIIASIS
FINDINGS
2
yes
3
yes
yes
NUMBER PROCEDURE
OF
STONE
STONES
LOCATION
enterolithotomy
terminal ileum
enterolithotomy
terminal ileum terminal ileum terminal ileum proximal ileum
enterolithotomy
4
enterolithotomy
5
segmental intestinal.
MISCELLANEOUS
recovered from pulmonary embolism and wound infection postoperatively
resection
6
yes
yes
enterolithotomy
7
yes
yes
enterolithotomy
yes
enterolithotomy
8 9
segmental intestinal resection,
cholecystectomy repair of fistula, common bile duct exploration
multiple
proximal jejunum 2nd portion of duodenum terminal ileum mid ileum
returned for elective fistula repair
died in early postoperative period
.
"""
246
SAMUEL B. VANLANDINGHAM AND CHARLES WILLIAM BRODERS
Findings on physical examination were consistent with mechanical bowel obstruction. There were no unique signs on physical examination that aided in elucidating the etiology of the obstruction. In three of the nine patients, a presumptive diagnosis of gallstone ileus was made preoperatively. In four of the nine, a history of gallbladder disease was present. These four patients also had positive radiographic findings on abdominal plain films. Unfortunately, in one individual, the positive radiographic findings were not recognized until after the diagnosis had been made at laparotomy. All patients in our series underwent surgical exploration. Enterolithotomy alone was performed in seven subjects. Resection of the ileum alone was necessary in one patient because of perforation of the bowel at the site of the impaction ~f the stone. In another patient, a resection of the ileum was performed along with cholecystectomy and repair of the cholecystoenteric fistula. One patient was in the hospital for 16 days before undergoing surgical exploration. This patient displayed the signs and symptoms of the "tumbling phenomenon" and was advised to have surgery earlier but declined when she experienced dramatic relief of her symptoms. When the symptoms recurred, the patient eventually submitted to surgery and the gallstones were removed from her terminal ileum. In seven patients the obstructing stones were located in the ileum. One subject's stone was found to be impacted in the proximal jejunum, and in another, the stone was located near the second portion of the duodenum. In only one instance were multiple stones encountered. In two cases, perforation of the ileum had occurred and it was necessary to resect a short segment of intestine. Seven of nine patients survived surgery without complications and left the hospital after uneventful postoperative courses. One patient experienced both wound infection and pulmonary embolism but recovered from both and was subsequently discharged. One patient died from pulmonary complications after a stormy postoperative course. This single death occurred in the one patient who had a primary cholecystectomy and cholecystoenteric fistula repair combined with enterolithotomy. One patient who underwent enterolithotomy alone returned with recurrent pain in the right upper quadrant. Evaluation revealed an abnormal oral cholecystogram, and the patient underwent elective cholecystectomy and repair of the cholecystoenteric fistula.
SUMMARY Gallstone ileus, although uncommon, requires urgent and appropriate surgical therapy if unacceptable morbidity and mortality are to be avoided. Enterolithotomy alone remains the mainstay of operative treatment for gallstone ileus, but the additional performance of a one-stage cholecystectomy and repair of fistula is desirable if the condition of the patient will allow it. One must use good judgment in selecting a surgical procedure. It is imperative to recall that the primary goal in the surgical treatment of gallstone ileus is to save a life. Future complications of the diseased gallbladder and
247
GALLSTONE ILEUS
the cholecystoenteric fistula may be treated electively under more ideal circumstances when and if they occur. Gallstone ileus, like other complications of cholelithiasis, remains a strong argument for early cholecystectomy in patients with gallstones.
REFERENCES 1. Balch, F. G.: Gallstone ileus. N. Eng!. J. Med., 218:457-462, 1938. 2. Balthazar, E. J., and Schechter, L. S.: Air in gallbladder: A frequent finding in g;;lllstone ileus. Am. J. Roentgeno!., 131:219-222, 1978. 3. Berliner, S. D., and Burson, L. C.: One stage repair for cholecystoduodenal fistula and gallstone ileus. Arch. Surg., 90:313, 1965. 4. Bossart, P. A., Patterson, A. H., and Zintie, H. A.: Carcinoma of the gallbladder. Am. J. Surg., 103:361-364, 1962. 5. Buetow, G. W., Glaubatz, J. P., and Crampton, R S.: Recurrent gallstone ileus. Surgery, 54:716--724, 1963. 6. Cooperman, A. M., Dickson, E. R, and Remine, W. H.: Changing concepts in the surgical treatment of gallstone ileus. Ann. Surg., 167:377-383, 1968. 7. Courvoisier, L. T.: Zasurstitsch-Statistische Beitrage zur Pathologie und Chirurgie der Gallenwege. Leipzig, F. C. W. Vogel, 1890. 8. Day, E. A., and Marks, C.: Gallstone ileus: Review of the literature and presentation of thirtyfour new cases. Am. J. Surg., 129:552-558, 1975. 9. Foss, H. L., and Summers, J. D.: Intestinal obstruction from gallstones·. Ann. Surg., 115:721, 1942. 10. Fox, F. F.: Planning the operation for cholecystoenteric fistula with gallstone ileus. SURG. CLIN. NORTH AM., 50:93, 1970. 11. Hudspeth, A. S., and McGuirt, W. F.: Gallstone ileus, a continuing surgical problem. Arch. Surg., 100:668--672, 1970. 12. Kasahara, Y., Umemura, H., and Shiraha, S.: Gallstone ileus: Review of 112 patients in the Japanese literature. Am. J. Surg., 140:437-440, 1980. 13. Raiford, T. S.: Intestinal obstruction caused by gallstones. Am. J. Surg., 104:383--394, 1962. 14. Rigler, L. G., Borman, C. N., and Noble, J. F.: Gallstone obstruction: Pathogenesis and roentgen manifestations. J.A.M.A., 117:1753,1941. 15. Sedlack, R E., Hodgson, J. R, Butt, H. R., et al.: Gas in the biliary tract. Clinical and experimental observations. Gastroenterology, 41 :551-556, 1961. 16. Tuell, S. W.: Gallstone ileus: Is cholecystectomy indicated? Am. Surg., 31 :473-475, 1965. 17. Turner, G. G.: A giant gallstone impacted in th<:J colon and causing acute obstruction. Br. J. Surg., 42:210, 1954. 18. Vick, R M.: Statistics of acute intestinal obstruction. Brit. Med., 2:546, 1932. 19. Wakefield, E. G., Vickers, P. M., and Walters, W.: Cholecystoenteric fistulas. Surgery, 5: 674-677, 1939. 20. Warshaw, A. L., and Bartlett, M. K.: Choice of operation for gallstone intestinal obstruction. Ann. Surg., 164:1051, 1966. Division of General Surgery Scott and White Clinic Temple, Texas 76508 (Dr. Broders)
Gallstone Ileus Samuel B. VanLandingham, M. D.,* and Charles William Broders, M.D. t
Gallstone ileus, first described by Bartholin in 1654, is mechanical intestinal obstruction caused by· impaction of one or more gallstones within the lumen of the bowel. Courvoisier reported 131 cases of gallstone ileus in 1890 with a mortality of 44 per cent in the 125 surgical operations performed for the condition. 7 Gallstone ileus is sufficiently uncommon that most surgeons have only a very limited experience with it. The incidence of small bowel obstruction due to gallstones is reported to be between 1 and 3 per cent.I8 This increases to 25 per cent in patients aged 65 years or older.13 Raiford states that the average general surgeon can expect to encounter 1 case of gallstone ileus in every 300 cases of cholelithiasis and in every35 cases of intestinal obstruction. 13 Few surgical patients are as compromised medically as is the patient with gallstone ileus. Typically, gallstone ileus occurs in the sixth or seventh decade of life, an age at which there are often various other medical illnesses. In their series, Day and Marks 8 reported serious concomitant disease in 79 per cent of patients with gallstone ileus: diabetes mellitus in 50 per cent; major cardiovascular disease in 58 per cent; and major obesity in 58 per cent. For these reasons, gallstone ileus carries five times the mortality of any other nonmalignant cause of small bowel obstruction. ll
PATHOGENESIS Gallstone ileus is preceded by an initial episode of acute cholecystitis. Inflammation then develops in the tissues surrounding the gallbladder and adhesions form between the gallbladder and the intestine. The offending gallstone gradually erodes through the joined walls of the gallbladder and bowel to form a cholecystoenteric fistula through which the stone passes. In most cases, the fistula is located between the gallbladder and the duodenum, although other sites may be involved. Wakefield, Vickers, and Walters 19 from the Mayo Clinic reported that among 176 fistulas, the site of per'Resident, General Surgery, Scott and White Memorial Hospital, Temple, Texas tProfessor, Department of Surgery, Texas A. and M. University College of Medicine; Division of General Surgery, Scott and White Clinic, Temple, Texas
Surgical Clinics of North America-VoL 62, No.2, April 1982
241
242
SAMUEL B. VANLANDINGHAM AND CHARLES WILLIAM BRODERS
foration involved the duodenum in 101 cases, the colon in 33, the stomach in 7, and multiple sites in 11. Once within the intestinal tract, the gallstone may be vomited, it may pass spontaneously through the rectum, or it may become impacted and cause obstruction. Most reports indicate that stones smaller than 2.5 cm pass through the gastrointestinal tract spontaneously and are excreted uneventfully in the stools. lO Stones as large as 5 cm in diameter have passed spontaneously. J. A. Bargren in a personal communication to one of the authors (C. W. B.) stated that he plucked a gallstone from the rectum of a patient who had had intestinal obstruction that resolved itself with the passage of the stone down to the rectum. The largest gallstone causing intestinal obstruction measured 17.7 cm in its largest diameter and was removed from the transverse colonY The largest stone in our series measured 8 cm in greatest diameter, and the smallest measured only 2.3 cm in largest diameter. The site of obstruction is usually in the terminal ileum, the narrowest portion of the small bowe1. 9 In addition, there is some evidence to suggest that peristalsis is weaker here than it is in the more proximal intestine. 12 In our series of nine patients, the obstructing stone was located in the ileum in seven, in the proximal jejunum in one, and in the duodenum in one (Fig. 1).
Figure 1. Examination of the upper gastrointestinal tract demonstrates a large filling defect in the duodenum. Superimposed on the x-ray film is the actual gallstone extracted from the duodenum at laparotomy.
r
243
GALLSTONE ILEUS
DIAGNOSIS The diagnosis of gallstone ileus is quite difficult to make preoperatively. In a large series, the correct preoperative diagnosis was made in only four (33 per cent) of cases, with a resulting delay from the time of admission to the time of operation of two to three days on the average. Symptoms are often intermittent, as the obstructing gallstone can lodge at various levels in the bowel as it passes distally, giving incomplete small bowel obstruction. This is referred to as the "tumbling" phenomenon, indicating that the stone tumbles through the intestinal tract, causing either a transient complete or partial obstruction at various levels of the bowel. As each attack clears, the patient may feel much improved and may delay seeking medical attention, or upon seeking medical attention, the physician may be lulled into making a diagnosis of subsiding gastroenteritis. This delay in diagnosis and early surgical intervention adds to the morbidity and mortality of the disease. 8 Physical examination reveals only those findings characteristic of mechanical bowel obstruction. The patients are often acutely ill, dehydrated, and distended with high-pitched bowel sounds and tender abdomens. Laboratory studies are usually not specific but reflect deydration and electrolyte imbalance. Abdominal plain films are of major importance in establishing a diagnosis. Four of the nine patients in our series had positive plain film examinations suggestive of gallstone ileus. In 1941, Rigler, Borman, and Noble l4 described four roentgenographic signs in gallstone ileus, (1) air in the biliary tree, (2) radiographic evidence of partial or complete intestinal obstruction, (3) direct or indirect visualization of the obstructing stone by means of contrast medium in the intestine, and (4) change in the position of a previously observed stone. It should be noted that the presence of air in the biliary tree is not unique to gallstone ileus. Sedlock and others, reviewing 74 instances of pneumobilia in a Mayo Clinic study, found that 44 cases were due to previous surgical procedures of the biliary tract,16 These authors stress that an incompetent sphincter of Oddi can also permit the chronic reflux of gas into the biliary radicals. However, the presence of pneumobilia associated with the signs and symptoms of intestinal obstruction certainly strongly suggests gallstone ileus. 2
TREATMENT Operation is mandatory in the proper treatment of gallstone ileus. Delaying surgical intervention in the fond hope that the stone will pass spontaneously or that intestinal tube decompression will suffice are to be condemned. Balch reported an 87 per cent mortality rate in patients operated on with gallstone ileus who had symptoms longer than 72 hours' duration as opposed to a 45 per cent mortality rate when the symptoms were less than 72 hours' duration. l A short delay for hydrating the patient and correcting imbalance preoperatively is often necessary. These elderly individuals are
244
SAMUEL B. VANLANDINGHAM AND CHARLES WILLIAM BRODERS
often physiologically fragile and require close attention to their fluid and electrolyte disturbances, the control of their diabetes, infection, and other complicating conditions. The Swan-Ganz catheter is often an indispensable aid in monitoring fluid balance in these patients. The prime objective of all operations for gallstone ileus is to relieve the obstruction. In this regard, most authorities recommend enterolithotomy alone as the treatment of choice.l· 16 After identifying the offending stone, it is desirable to milk the stone proximally into uninvolved intestine. A longitudinal enterotomy incision is then performed and the stone is extracted. The enterotomy is then closed in a transverse fashion. If the stone is impacted in the intestine and cannot be easily milked retrograde into healthy tissue, a segmental bowel resection may be required. It is essential to examine the bowel, both small intestine and colon, for additional stones, since a 5 per cent reobstruction rate secondary to retained stones has been reported. 5 One must also examine the gallbladder and the cholecystoenteric fistula for evidence of leakage, abscess, or impending gangrene, as well as for additional stones. In recent years, many surgeons have advocated the one-stage repair for gallstone ileus in which cholecystectomy and repair of the cholecystoenteric fistula are combined with enterolithotomy.6. 10.20 This policy is supported by the increased risk of carcinoma of the gallbladder in patients with cholecystoenteric fistulas 4 and by a 30 per cent incidence of recurrent pain postoperatively in patients treated by enterolithotomy alone.20 Proponents of this approach stress careful selection of patients, since some are so severely debilitated that they will not tolerate prolonged surgical procedures. A review of the literature since the one-stage repair was introduced shows no significant increase in morbidity or mortality with the one-stage repair as opposed to enterolithotomy alone (Table 1). It is important to stress that the one-stage repair should only be performed under optimal conditions as far as the general condition of the patient and the associated pathologic findings are concerned. When the patient is too ill or the dissection required is too fraught with hazard, only relief of the obstruction itself should be performed. Upper gastrointestinal tract and biliary tract studies should be planned for the postoperative period in patients treated by enterolithotomy alone. A demonstration of cholelithiasis with or without symptoms postoperatively indicates the need for further surgical treatment, that is, cholecystectomy. Prior to 1925, the mortality rate due to gallstone ileus was a little over 60 per cent. But this figure has been reduced to less than 15 per cent in most Table 1.
Comparison of Mortality in Enterolithotomy and One-Stage Repair for Gallstone Ileus
Enterolithotomy One-stage repair TOTAL
*Average
NUMBER OF CASES
NUMBER OF DEATHS
156 35 191
17 7 24
% DEATHS 11
20 13*
T
245
GALLSTONE ILEUS
current series. Morbidity remains high, however, in that almost 75 per cent of patients undergoing surgical procedures for correction of gallstone ileus had significant wound infections postoperatively. Berliner and Burson reported a 15 per cent incidence of carcinoma of the gallbladder in patients with cholecystoenteric fistulas as compared with an incidence of only 0.8 per cent in patients with cholecystectomies performed for all other reasons. 3
SCOTT AND WHITE EXPERIENCE The hosptial records of nine consecutive cases of gallstone ileus occurring from 1954 to 1977 were reviewed. All nine patients had a diagnosis documented at laparotomy (Table 2). All nine of the subjects were females. The age of patients in the series ranged from 53 to 91 years, with a mean age of 75.4. All patients presented with abdominal pain, nausea, and vomiting. Other common presenting complaints were obstipation and abdominal distention. Arteriosclerotic heart disease, diabetes mellitus, and hypertension were frequent concomitant medical illnesses., Table 2.
Findings in Nine Patients with Gallstone Ileus Treated at the Scott and White Clinic POSITIVE
PATIENT
HISTORY OF
X-RAY
CIIOLELITIIIASIS
FINDINGS
2
yes
3
yes
yes
NUMBER PROCEDURE
OF
STONE
STONES
LOCATION
enterolithotomy
terminal ileum
enterolithotomy
terminal ileum terminal ileum terminal ileum proximal ileum
enterolithotomy
4
enterolithotomy
5
segmental intestinal.
MISCELLANEOUS
recovered from pulmonary embolism and wound infection postoperatively
resection
6
yes
yes
enterolithotomy
7
yes
yes
enterolithotomy
yes
enterolithotomy
8 9
segmental intestinal resection,
cholecystectomy repair of fistula, common bile duct exploration
multiple
proximal jejunum 2nd portion of duodenum terminal ileum mid ileum
returned for elective fistula repair
died in early postoperative period
.
"""
246
SAMUEL B. VANLANDINGHAM AND CHARLES WILLIAM BRODERS
Findings on physical examination were consistent with mechanical bowel obstruction. There were no unique signs on physical examination that aided in elucidating the etiology of the obstruction. In three of the nine patients, a presumptive diagnosis of gallstone ileus was made preoperatively. In four of the nine, a history of gallbladder disease was present. These four patients also had positive radiographic findings on abdominal plain films. Unfortunately, in one individual, the positive radiographic findings were not recognized until after the diagnosis had been made at laparotomy. All patients in our series underwent surgical exploration. Enterolithotomy alone was performed in seven subjects. Resection of the ileum alone was necessary in one patient because of perforation of the bowel at the site of the impaction ~f the stone. In another patient, a resection of the ileum was performed along with cholecystectomy and repair of the cholecystoenteric fistula. One patient was in the hospital for 16 days before undergoing surgical exploration. This patient displayed the signs and symptoms of the "tumbling phenomenon" and was advised to have surgery earlier but declined when she experienced dramatic relief of her symptoms. When the symptoms recurred, the patient eventually submitted to surgery and the gallstones were removed from her terminal ileum. In seven patients the obstructing stones were located in the ileum. One subject's stone was found to be impacted in the proximal jejunum, and in another, the stone was located near the second portion of the duodenum. In only one instance were multiple stones encountered. In two cases, perforation of the ileum had occurred and it was necessary to resect a short segment of intestine. Seven of nine patients survived surgery without complications and left the hospital after uneventful postoperative courses. One patient experienced both wound infection and pulmonary embolism but recovered from both and was subsequently discharged. One patient died from pulmonary complications after a stormy postoperative course. This single death occurred in the one patient who had a primary cholecystectomy and cholecystoenteric fistula repair combined with enterolithotomy. One patient who underwent enterolithotomy alone returned with recurrent pain in the right upper quadrant. Evaluation revealed an abnormal oral cholecystogram, and the patient underwent elective cholecystectomy and repair of the cholecystoenteric fistula.
SUMMARY Gallstone ileus, although uncommon, requires urgent and appropriate surgical therapy if unacceptable morbidity and mortality are to be avoided. Enterolithotomy alone remains the mainstay of operative treatment for gallstone ileus, but the additional performance of a one-stage cholecystectomy and repair of fistula is desirable if the condition of the patient will allow it. One must use good judgment in selecting a surgical procedure. It is imperative to recall that the primary goal in the surgical treatment of gallstone ileus is to save a life. Future complications of the diseased gallbladder and
247
GALLSTONE ILEUS
the cholecystoenteric fistula may be treated electively under more ideal circumstances when and if they occur. Gallstone ileus, like other complications of cholelithiasis, remains a strong argument for early cholecystectomy in patients with gallstones.
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