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Gallstone ileus pyloric obstruction caused by gallstone
GALLSTONE PYLORIC
OBSTRUCTION
WILLIAM I. SHEINFELD, M.D.
CAIJSED
HARRY MACKLER, M.D. Associate
NEW
BROOKLYN,
G
Surgeon, Ccmey Isl:wi
Hospitd
YORK
ever, enemas were evocative
of smal1 amounts of fecaI matter and ffatus. General physical examination proved to be essential+ negative,
ALLSTONE iIeus is an uncommon condition in the experience of any one ph_vsician or surgicaf service. Nevertheless, It occurs often enough to be considered more frequentIy as a diagnostic entity and attempts shouId be made to reduce the high attendant mortaIity (30 to 60 per cent).‘.” IIeus, as a compIication of biliary tract disease, is considered difficult or impossible of recognition by many authors.“223 It is our contention that it may be suspected with enough frequency so that earIy surgery &II be performed to supplant the usuaI Iate ineffective surgery. Continued publication and discussion of case reports will bring this cIinica1 entity to the attention of physicians. The IikeIihood of earlier diagnosis and suitable therapy in genera1 wili be greater, and eventualIS the mortality wifI be reduced. GalIstone iIeus comprises 3 to 5 per cent of all intestina1 obstructions.2*3 This case is presented with the above mentioned reasons in mind. Two features are noteworth
A white female, sixty-two years of age, was admitted to the medical service at the Coney IsIand hospital on October 16, 1942, with the primary complaint of persistent vomiting for the past seven days. There was no pain. There had been several previous attacks simiIar to this and a two-year history of galIbIadder disease without jaundice. During the present iIIness there was marked constipation, HOW* From The Coney Island Hospital,
BY GALLSTONE
AND
Assistant Surgeon, Coney island Hospitaf
CASE
ILEUS*
The abdomen was penduIous wrth slight tenderness on deep pressure in the upper right quadrant. A provisional diagnosis of chronic cholecystitis, miId acidosis, chronic bronchitis and arteriosclerotic heart disease was made. Routine laboratory findings reveaied a positive Wassermann, and leukocytosis on October zoth of r~,ooo white blood cells with 83 per cent polymorphonucIears, which was reduced by October 26th to IO,OOO white blood celis with 73 per cent pol~~lorphonucIears. Blood chemistry tests showed glucose 129 mg. per cent, urea nitrogen 12.5 mg. per cent, and creatinine 2.9 mg. per cent. Urinalysis was negative. A flat x-ray plate of the abdomen on October 19th revealed a large caIculus in the right upper quadrant apparently within the gaIIbladder. (Fig. I .) The diagnosis was cholciithiasis. The patient was kept on the medical service until October ajrd, when she was transferred to surgery. Symptoms persisted without abatement. Repeated attempts to intubate the duodenum were unsuccessful. X-rays showed no evidence of intestinal obstruction. On October z?th, the diagnosis of gallstone ileus was made. As soon as the patient could be properly prepared operation was performed. The stomach was greatly distended and contained a hard mass at the pylorus, which subsequentIy proved to be the gallstone. The galIbIadder was small, contracted, cicatrized and contained neither bile nor calculi. There was a fistulous tract from the gallbladder to the duodena1 gastric junction. The caMus was impacted in the duodenum and extended through the pyiorus into the stomach. In order to clarify the picture ofthe condition invoIved, the gallbladder 1~~s separated from
Service of Dr. George \Vehh, Brot)klvri. 439
440
Arncrican
Journal
of Surgery
Sheinfeld,
Mackler-GaIlstone
the stomach. This opened the gaIIbIadderduodena1 fistula. Incision was made into the stomach and the caIcuIus extracted. The open-
REMARKS
At first it was considered that chronic choIecystitis was the cause of the persistent vomiting. IntestinaI obstruction was not recognized. This is the usua1 time-honored error recorded in numerous reports on the subject.5 However, if we accept the modern trend and consider acute gaIIbIadder conditions an indication for immediate surgery, after suitable preparation, this error wiI1 not continue. AutomaticaIIy, a11 reasons for deIay in operation upon patients with gaIIstone iIeus wiI1 vanish and earIy surgery wiI1 resuIt even if the compIication of iIeus is not recognized. It is ironica that where from the point of view of IocaI disturbance, the prognosis
SEPTEMBER, ,913
shouId be good, it is nevertheIess poor. The probIems of local gangrene or compromise of the circmation of the segment of gut
FIG. I. X-ray demonstrating
ing in the stomach was closed and the diseased gaIIbIadder was removed. The patient responded poorIy to the operation, developing hyperthermia and circuIatory collapse several hours afterward. In spite of supportive therapy, glucose intravenousIy, transfusion, and the use of oxygen, the patient expired on the first postoperative day.
IIeus
large calcuIus.
invoIved, are almost always absent. The obstruction can be readiIy relieved by simpIe enterotomy, caIcuIus extraction and intestina1 repair. However, because of the poor genera1 condition of the patient, the operative compIications and mortality are high. If there has been a prolonged period of vomiting prior to surgery, simpIe reIief of the obstruction without operative attention to the gaIIbIadder must be practiced, in spite of a11 temptation to divide adhesions and attack the diseased gaIIbIadder. The presence of a choIecystoduodena1 or gastric fistuIa is not incompatibIe with proIonged life in a good state of heaIth.2 ShouId there be subsequent symptoms referabIe to interna gaIIbIadder fistma, further surgery can be carried out at a Iater date, when there is no associated probIem of intestina1 obstruction with the attendant derangement in bIood chemistry, hemoconcentration, etc. FrequentIy, gaIIbIadder intestina1 listulas wiI1 cIose spontaneousIy after the caIcuIus has passed.4
.1, w SP.HILS VI,,
I-XI,
NC,.
3
Sheinfeld,
MackIer--Gallstone
The site of the obstruction is usuaIIy the terminal ileum 2~4*i338at varying distance from the ileocdcal valve, depending upon
.I
of the acute phase of the ailment, numerous attacks of coIicky abdominal pain associated with persistent vomiting but incom-
FIG. 2. Photographs
the size of the caIculus and the diameter of the intestinal Iumen. One or several caIcuIi may be present in the gut. In this case due to the exceedingIy Iarge size, the caIcuIus was in the duodenum and extended through the pyIorus into the antral portion of the stomach. The obstruction was at first cIassicalIy intermittent becoming aImost complete as the clinical picture deveIoped. After a review of many reported cases,1-12 we believe that the symptomatoIogy conforms with a definite pattern, though occasionally it may be diffIcuIt to recognize. There is usuaIIy a history of chronic gaIIbIadder disease of varying duration, months to years. Then there is the onset
Ileus
of c:&xlus.
Feces and gas continue plete obstruction. to be passed almost until the time of Association of incompIete or operation. occasionally compIete intestina1 obstruction with a history of chronic gaIIbIadder disease in an eIderIy individual shouId arouse suspicion to the presence of gallstone iIeus. A fiat x-ray pIate of the abdomen mav be of help; a large ca1cuIus may be visuaIized. These cases are caused by Iarge calculi. The typical findings of small bowe1 obstruction may be present, that is, the diIated intestinal loop with Auid Ievels or VisuaIization of valvulae conniventes. OccasionaIIy, as a result of the gaIIbIadder intestinal fistula, air may be seen outlining the common and hepatic
442
American
_hd
d surgery
SheinfeId,
MackIer-GaIIstone
ducts or even the gallbladder. A smaI1 amount of barium given by mouth may be seen entering the biIiary tract.” CONCLUSION
A case of galIstone iIeus is presented. The importance of this syndrome, its diagnostic features and therapy are discussed. REFERENCES I. COI.COCK, BENTLY P. Intestinal obstruction due to gaIlstones. Lahey Clin. Bull., 2: 47, 1940. 2. MCQUEENEY, A. M. Intestinal biIiary fistuIa and intestina1 obstruction due to gaIlstones. Ann. Slug., 110: 50-54, 1939. 3. DULIN, J. W. and PETERSON, F. R. IntestinaI obstruction due to g&tones. Arch. Surg., 38: 351, 1939.
1Ieu.s
SEPTEMBEH, ,943
4. WAKEFIELD, E. G., VICKERS, P. N. and WALTERS, W. IntestinaI obstruction caused by gaIIstone. Surgery 5 : 670-3, 1939. 5. DIAK, S. L. and FAGAN, E. R. IntestinaI obstruction due to gallstone. Surg. Clin. North America, 14: 1325, 1934. 6. PAUL. L. W. ChoIecvsto-duodena1 fistula with gaIistone obstruction” of smaI1 intestine. Radiology, 23: 363-5, 1934. 7. GARDINER, H. IntestinaI obstruction by gaIIstone. hZCet, 2: 354, 1933. 8. ROSENTHAL, J. IntestinaI obstruction caused by impacted gaIIStOneS. LanCet, 2: 192-3, 1934. 9. MAST, W. H. Recurrent intestina1 obstruction due to gaIlstone. Am. J. Surg., 32: 516-18, 1936. IO. SNYDER. L. H. Unrecoanized gaIIstone obstruction of the intestine. .5&t%.M. .f, 3 I : I 275-6, 1938. I I. SKEMP, A., and TRAVNICEK, F. G. GaIIstone obstruction of the bowel. Am. J. Surg., 32: 166-68, 1936. 12. WAUGH, J. M. DuodenaI obstruction secondary to chronic choIecystitis with choIecystoduodena1 fistula. Proc. .%a$ Meet., Mayo Clin., 12: 694-8, ‘937.
OBSTRUCTION
WILLIAM I. SHEINFELD, M.D.
CAIJSED
HARRY MACKLER, M.D. Associate
NEW
BROOKLYN,
G
Surgeon, Ccmey Isl:wi
Hospitd
YORK
ever, enemas were evocative
of smal1 amounts of fecaI matter and ffatus. General physical examination proved to be essential+ negative,
ALLSTONE iIeus is an uncommon condition in the experience of any one ph_vsician or surgicaf service. Nevertheless, It occurs often enough to be considered more frequentIy as a diagnostic entity and attempts shouId be made to reduce the high attendant mortaIity (30 to 60 per cent).‘.” IIeus, as a compIication of biliary tract disease, is considered difficult or impossible of recognition by many authors.“223 It is our contention that it may be suspected with enough frequency so that earIy surgery &II be performed to supplant the usuaI Iate ineffective surgery. Continued publication and discussion of case reports will bring this cIinica1 entity to the attention of physicians. The IikeIihood of earlier diagnosis and suitable therapy in genera1 wili be greater, and eventualIS the mortality wifI be reduced. GalIstone iIeus comprises 3 to 5 per cent of all intestina1 obstructions.2*3 This case is presented with the above mentioned reasons in mind. Two features are noteworth
A white female, sixty-two years of age, was admitted to the medical service at the Coney IsIand hospital on October 16, 1942, with the primary complaint of persistent vomiting for the past seven days. There was no pain. There had been several previous attacks simiIar to this and a two-year history of galIbIadder disease without jaundice. During the present iIIness there was marked constipation, HOW* From The Coney Island Hospital,
BY GALLSTONE
AND
Assistant Surgeon, Coney island Hospitaf
CASE
ILEUS*
The abdomen was penduIous wrth slight tenderness on deep pressure in the upper right quadrant. A provisional diagnosis of chronic cholecystitis, miId acidosis, chronic bronchitis and arteriosclerotic heart disease was made. Routine laboratory findings reveaied a positive Wassermann, and leukocytosis on October zoth of r~,ooo white blood cells with 83 per cent polymorphonucIears, which was reduced by October 26th to IO,OOO white blood celis with 73 per cent pol~~lorphonucIears. Blood chemistry tests showed glucose 129 mg. per cent, urea nitrogen 12.5 mg. per cent, and creatinine 2.9 mg. per cent. Urinalysis was negative. A flat x-ray plate of the abdomen on October 19th revealed a large caIculus in the right upper quadrant apparently within the gaIIbladder. (Fig. I .) The diagnosis was cholciithiasis. The patient was kept on the medical service until October ajrd, when she was transferred to surgery. Symptoms persisted without abatement. Repeated attempts to intubate the duodenum were unsuccessful. X-rays showed no evidence of intestinal obstruction. On October z?th, the diagnosis of gallstone ileus was made. As soon as the patient could be properly prepared operation was performed. The stomach was greatly distended and contained a hard mass at the pylorus, which subsequentIy proved to be the gallstone. The galIbIadder was small, contracted, cicatrized and contained neither bile nor calculi. There was a fistulous tract from the gallbladder to the duodena1 gastric junction. The caMus was impacted in the duodenum and extended through the pyiorus into the stomach. In order to clarify the picture ofthe condition invoIved, the gallbladder 1~~s separated from
Service of Dr. George \Vehh, Brot)klvri. 439
440
Arncrican
Journal
of Surgery
Sheinfeld,
Mackler-GaIlstone
the stomach. This opened the gaIIbIadderduodena1 fistula. Incision was made into the stomach and the caIcuIus extracted. The open-
REMARKS
At first it was considered that chronic choIecystitis was the cause of the persistent vomiting. IntestinaI obstruction was not recognized. This is the usua1 time-honored error recorded in numerous reports on the subject.5 However, if we accept the modern trend and consider acute gaIIbIadder conditions an indication for immediate surgery, after suitable preparation, this error wiI1 not continue. AutomaticaIIy, a11 reasons for deIay in operation upon patients with gaIIstone iIeus wiI1 vanish and earIy surgery wiI1 resuIt even if the compIication of iIeus is not recognized. It is ironica that where from the point of view of IocaI disturbance, the prognosis
SEPTEMBER, ,913
shouId be good, it is nevertheIess poor. The probIems of local gangrene or compromise of the circmation of the segment of gut
FIG. I. X-ray demonstrating
ing in the stomach was closed and the diseased gaIIbIadder was removed. The patient responded poorIy to the operation, developing hyperthermia and circuIatory collapse several hours afterward. In spite of supportive therapy, glucose intravenousIy, transfusion, and the use of oxygen, the patient expired on the first postoperative day.
IIeus
large calcuIus.
invoIved, are almost always absent. The obstruction can be readiIy relieved by simpIe enterotomy, caIcuIus extraction and intestina1 repair. However, because of the poor genera1 condition of the patient, the operative compIications and mortality are high. If there has been a prolonged period of vomiting prior to surgery, simpIe reIief of the obstruction without operative attention to the gaIIbIadder must be practiced, in spite of a11 temptation to divide adhesions and attack the diseased gaIIbIadder. The presence of a choIecystoduodena1 or gastric fistuIa is not incompatibIe with proIonged life in a good state of heaIth.2 ShouId there be subsequent symptoms referabIe to interna gaIIbIadder fistma, further surgery can be carried out at a Iater date, when there is no associated probIem of intestina1 obstruction with the attendant derangement in bIood chemistry, hemoconcentration, etc. FrequentIy, gaIIbIadder intestina1 listulas wiI1 cIose spontaneousIy after the caIcuIus has passed.4
.1, w SP.HILS VI,,
I-XI,
NC,.
3
Sheinfeld,
MackIer--Gallstone
The site of the obstruction is usuaIIy the terminal ileum 2~4*i338at varying distance from the ileocdcal valve, depending upon
.I
of the acute phase of the ailment, numerous attacks of coIicky abdominal pain associated with persistent vomiting but incom-
FIG. 2. Photographs
the size of the caIculus and the diameter of the intestinal Iumen. One or several caIcuIi may be present in the gut. In this case due to the exceedingIy Iarge size, the caIcuIus was in the duodenum and extended through the pyIorus into the antral portion of the stomach. The obstruction was at first cIassicalIy intermittent becoming aImost complete as the clinical picture deveIoped. After a review of many reported cases,1-12 we believe that the symptomatoIogy conforms with a definite pattern, though occasionally it may be diffIcuIt to recognize. There is usuaIIy a history of chronic gaIIbIadder disease of varying duration, months to years. Then there is the onset
Ileus
of c:&xlus.
Feces and gas continue plete obstruction. to be passed almost until the time of Association of incompIete or operation. occasionally compIete intestina1 obstruction with a history of chronic gaIIbIadder disease in an eIderIy individual shouId arouse suspicion to the presence of gallstone iIeus. A fiat x-ray pIate of the abdomen mav be of help; a large ca1cuIus may be visuaIized. These cases are caused by Iarge calculi. The typical findings of small bowe1 obstruction may be present, that is, the diIated intestinal loop with Auid Ievels or VisuaIization of valvulae conniventes. OccasionaIIy, as a result of the gaIIbIadder intestinal fistula, air may be seen outlining the common and hepatic
442
American
_hd
d surgery
SheinfeId,
MackIer-GaIIstone
ducts or even the gallbladder. A smaI1 amount of barium given by mouth may be seen entering the biIiary tract.” CONCLUSION
A case of galIstone iIeus is presented. The importance of this syndrome, its diagnostic features and therapy are discussed. REFERENCES I. COI.COCK, BENTLY P. Intestinal obstruction due to gaIlstones. Lahey Clin. Bull., 2: 47, 1940. 2. MCQUEENEY, A. M. Intestinal biIiary fistuIa and intestina1 obstruction due to gaIlstones. Ann. Slug., 110: 50-54, 1939. 3. DULIN, J. W. and PETERSON, F. R. IntestinaI obstruction due to g&tones. Arch. Surg., 38: 351, 1939.
1Ieu.s
SEPTEMBEH, ,943
4. WAKEFIELD, E. G., VICKERS, P. N. and WALTERS, W. IntestinaI obstruction caused by gaIIstone. Surgery 5 : 670-3, 1939. 5. DIAK, S. L. and FAGAN, E. R. IntestinaI obstruction due to gallstone. Surg. Clin. North America, 14: 1325, 1934. 6. PAUL. L. W. ChoIecvsto-duodena1 fistula with gaIistone obstruction” of smaI1 intestine. Radiology, 23: 363-5, 1934. 7. GARDINER, H. IntestinaI obstruction by gaIIstone. hZCet, 2: 354, 1933. 8. ROSENTHAL, J. IntestinaI obstruction caused by impacted gaIIStOneS. LanCet, 2: 192-3, 1934. 9. MAST, W. H. Recurrent intestina1 obstruction due to gaIlstone. Am. J. Surg., 32: 516-18, 1936. IO. SNYDER. L. H. Unrecoanized gaIIstone obstruction of the intestine. .5&t%.M. .f, 3 I : I 275-6, 1938. I I. SKEMP, A., and TRAVNICEK, F. G. GaIIstone obstruction of the bowel. Am. J. Surg., 32: 166-68, 1936. 12. WAUGH, J. M. DuodenaI obstruction secondary to chronic choIecystitis with choIecystoduodena1 fistula. Proc. .%a$ Meet., Mayo Clin., 12: 694-8, ‘937.