Creeping Stroke - Venous thrombosis presenting with pc-stroke.pptx
Management of patients with Gallstone Ileus
1.
2. Surgical Approach to Patient with
Gallstone Ileus
Presenters:
Dr Kashmala
Dr Namerah Nasir
HOD Surgery:
Prof Brig (R) M. Farooq Dar
MBBS, FCPS, OJT (Plastic Surgery)
7. History of Present Illness
• Abdominal pain : markedly in eigastrium. Umblical and hypogastrium
since that morning
colicky
sudden
persistent
7/10 intensity
• Vomiting: having food particles
• Absolute contipation
• No noticeable weight loss, fatigue
• No blood in stools/melena
8. PMH: No Known Co morbids
PSH: No previous surgeries
Family Hx: HTN
Drug Hx: Currently not on any medications
Allergy: NKDA
9. Vitals: 100/70, 100 bpm, 18RR, >95% Saturation on RA, A/F
GPE: Lying comfortably in bed
Oriented to time place and person
No pallor, jaundice, palpable LNs
Abdominal: Distended, tender, guarding with BS +ve
Chest: B/L clear, no added sounds
CVS: RRR, no added sounds
DRE: Empty collapsed rectum with no palpable mass
Examination
10. • Admission in SICU
• Hematological and Radiological Investigations
• PAA
• Surgery
Management
12. Radiological Investigations
XRAY ERECT AND SUPINE ABDOMEN:
• Dilated gut loops with prominent Valvulae conniventes and multiple air
fluid levels.
USG ABDOMEN/PELVIS:
• LIVER: Increased Parenchymal Echogenecity
• Gall Bladder: Contracted Postprandial
• Pancreas: Most Of The Part Obscured By Excessive Gas Shadows
• Right Kidney Ureter: Showed Concretions With Hydronephroureter In
Proximal Portion Of Ureter
• Prostate: 95gms
13. Radiological Investigations . Cont..
CECT ABDOMEN/PELVIS:
• Pneumobilia, i.e. air in biliary sytem
Ovoid low attenuation structure in the ileal loop on right side
Distended small bowel loops
16. Surgical Management
DIAGNOSIS:
GALLSTONE ILEUS + B/L Renal and Vesicle calculi
• Urology team taken on board and they planned for cystoscopy and
B/L URS.
• From surgical side:
Pt prepared for Exploratory Laparotomy and enterolithotomy
Pre anesthesia assesment
Cardiology consultation
Arrangement of Blood products
Informed written consent
Shifted to OT for surgery
20. • Shifted to SICU
• POD # 1
TLC: 7.4
HB:11.5
K: 3.0
• POD # 3 – NG removed, started on oral sips
• POD # 5 – Drain removed, shifted to room
• POD # 6 – liquid diet
• POD # 7 – soft diet
• POD # 08 – discharged to home
Post-operative course
23. Definition & Epidemiology
• GALLSTONE ILEUS- A misnomer
It is a true mechanical intestinal obstruction caused by
gall stones
o Incidence:
-> 30-35/1000000 cases.
-> 0.3-0.5% in pt with cholelithiasis
-> <5% of cases of intestinal obstruction
-> Elderly patients
-> Higher incidence in females
25. Pathophysiology
The most frequent fistula occurs between the gallbladder and the
duodenum
Fistula type Range (%)
Cholecystoduodenal 32.5-96.5
Cholecystogastric 0-13.3
Cholecystojejunal 0-2.5
Cholecystoileal 0-2.5
Cholecystocolic 0-10.9
Choledochoduodenal 0-13.4
Undetermined 0-65
26. Pathophysiology
• Sites of impaction:
-> If stone size is less 2.5 cm it can easily be passed through rectum.
-> Most common site of obstruction is at terminal ileum/ileocecal valve –
narrow lumen and potentially less active paristalisis.
-> Rarely if fistula is between gallbladder and stomach, stone can be
vomited out.
-> If impacted at duodenum – Bouveret’s syndrome.
27. Pathophysiology
Site Range (%)
Duodenum 0-10.5
Stomach 0-20
Jejunum 0-50
Jejunum/proximal ileum 0-50
Ileum 0-89.5
Colon 0-8.1
Undetermined 0-25
Site of gastrointestinal obstruction in patients with gallstone ileus
28. Clinical Presentation
Patient presents with the history of prior biliary symptoms or no prior
symptoms
Same as in any mechanical intestinal obstruction,
-> Abdominal pain – crampy, intermittent
-> Vomiting – gastric contents then feculent – depending on the site of
obstruction
-> Distention
-> Absolute constipation
29. Clinical Presentation
Physical examination:
-> generalised abdominal tenderness with guarding
-> variable distention
-> high pitched bowel sounds
-> Obstructive jaundice
If perforation ensues,
-> fever
-> toxicity
->physical signs of dehydration
30. WORK UP
-> Baseline investigations
-> Radiological Investigations
- X-ray
- CT Scan
- MRCP
31. Workup
Plain abdominal radiograph:
(1) pneumobilia or contrast material
in the biliary tree
(2) partial or complete intestinal
obstruction seen by distended bowel
loops
(3) an aberrant gallstone; and
(4) change of the position of such
gallstone on serial films
33. Workup
Computed tomography:
-> Superior to plain abdominal films or US
-> Sensitivity of up to 93%
In a retrospective study by Lassandro et al.
CT SCAN(%) X RAY(%)
RIGLER TRIAD 77 14
DISTENDED BOWEL
LOOPS
92 08
PNEUMOBILIA 89 11
ECTOPIC GALLSTONE 81 19
AIR FLUID LEVELS 37 63
BILIO DIGESTIVE FISTULA 14
36. Surgical Management
GOALS OF MANAGEMENT:
-> Relief of intestinal obstruction
-> Correction of electrolyte imbalances and metabolic derangements
SURGICAL MANAGEMENT:
-> Open surgery – main stray of treatment.
-> Laparascopic surgery
37. Surgical Management
Surgical Management:
(1) simple enterolithotomy;
(2) enterolithotomy, cholecystectomy and fistula closure (one-stage
procedure)
(3) enterolithotomy with cholecystectomy performed later (two-stage
procedure).
38.
39. One stage VS Two stage surgery
Based on Reisner and Cohen studies:
Mortality rate – 11.7% - Simple enterolithotomy
16.9% - One stage surgery
One Stage surgery – excessively invasive and more postoperative
complications.
Two stage surgery- Associated risk of recurrence
Retrograde cholecystitis
Carcinoma
40. Effects of persistent cholecysto intestinal fistula
Risk Factor for:
Recurrent gallstone ileus - 86.7%
Symptomatic Cholelithiasis - needs cholecystectomy
Ascending Cholangitis – Cholecystodudenal fistula – 11%
Cholecystocolonic fistula – 60%
Gallbladder Cancer – 15%
Natural closure of cholecystointestinal fistula as a possible outcome
Natural fistula closure without treatment of the biliary - 61.5% of cases
41. RECENT ADVANCES
-> Recent advancement
- Endoscopic removal of stones.
Reserved for patients with
Bouveret syndrome (Upper Endoscopy)
Ileal or colonic obstruction (colonoscopy)
- Lithotripsy
Stones are fragmented by ESWL
Small stones either passed in stool
or removed endoscopically
-> Still under development.
Too few cases so results couldn’t be concluded.
Assalam o alaekum. My name is Dr. Kashmala and I’m a house officer in the surgery department. Today along with Dr. Namerah, we will be presenting a case of Gallstone ileus, followed by remarks from our HOD Brig Farooq Dar.
This will be the layout of the presentation. I will present the case, which will be followed by discussion by Dr. Namerah and concluding remarks by Brig Dar.
So, our pt, a 64 year old male, resident of Islamabad, presented to PAF hospital Unit 1 ED on 4th July, with complaints of…
Abdominal pain, 3 episodes of vomiting and inability to pass flatus since that morning
Our patient was in his general state of health till morning of 4th july 2023, when he developed colicky abdominal pain after having breakfast, it was markedly in mid abdomen, it was sudden in onset, persistent with an intensity of 7/10 and there were no aggravating or relieving factors He also had 3 episodes of vomiting 2 cups full in total containing the contents of his breakfast. However, he did not have any other gastrointestinal or genitourinary symptoms and was without any complaints of fever. He didn’t notice any bleeding per rectum or melena. He also didn’t notice any weight loss or fatigue.
He had non significant past medical and surgical history. In family history, his mother suffered from HTN. He wasn’t currently on any medications, and there weren’t any known drug allergies. He didn’t have any hx of dypepsia, biliary colics or othere biliary symptoms.
On examination, pt was vitally stable. He was lying comfortably in bed, oriented to time, place and person, without any signs of pallor, jaundice, or any palpable lymph nodes. On inspection of the abdomen, there was marked distension with tenderness in epigastrium, umblical region and hypogastrium. Guarding was present. There was no palpable mass or fullness on examination. Bowel sounds were exeggerated. No abnormality was detected on chest or cardiovascular exam. On DRE he had empty rectum with no blood on rectal vault.
Pt was reviewed by the surgical team and a provisional diagnosis of Acute Abdomen secondary to acute intestinal obstruction was made. He was admitted in SICU. abx, painkillers, antiemetics and glycerine suppositries were prescribed. Baseline investigations were sent and radiological Investigations were done.
Patients baseline investigations showed infective picture with TLC of 15.3 and CRP of 372. Rest of the workup was in normal limits
XRAY ERECT AND SUPINE ABDOMEN showed Dilated gut loops with prominent Valvulae conniventes and multiple air fluid levels pointing towards small bowel obstruction. On usg abdomen and pelvis Galbladder was contracted post prandially so any stone or sludge couldn’t be visualized at the time of scan. Repeat scan after fasting of 6 hours was advised. In rest of scan, Right Kidney and Ureter Showed Concretions With Hydronephroureter in Proximal Portion Of Ureter and Prostate was enlarged.
Pt was given a trial of conservative management. After 24 hrs, pt’s pain was not settled and constipation was not relieved even after Kleen enema so we proceeded towards CECT abdomen+ pelvis, which showed pneumobilia, i.e. air in biliary sytem, ovoid low attenuation structure with partial calcific peripheral rim in the ileal loop on right side at the level of mid abdomen, distended small bowel loops and collapsed large bowel with colonic diveticula. Radiological diagnosis of GALLSTONE ILEUS was made on the basis of rigler triad found on CECT.
Apart from this, pt had multiple calculi in bilateral kidneys, right hydronephroureter and vesicle calculi as well.
Here we can see pnumobilia, connection of gallbladder with gut loops – duodenum making cholecystoduodenal fistula, in 2nd picture we can see ovoid low attenuation structure with partial calcific peripheral rim, most probably gallstone.
MRCP was advised for the confirmation of diagnosis, it showed Defect in the gall bladder wall along its inferior aspect communicating with the supero-lateral wall of junction of first and second part of dudenum suggesting Cholecysto-duodenal fistula (Picture 2).There were intraluminal signal void areas representing air foci and mildly dilated intrahepatic billary channels with associated pneumobilia, secondary cholecysto -duodenal fistula formation.(Picture 1)
After Definitive diagnosis of Gallstone ileus and Bilateral renal and vesicle calculi, Urology team was taken on board and they planned for cystoscopy and B/L URS.
From surgical side: Pt was prepared for Exploratory Laparotomy and enterolithotomy. Patient’s Pre anesthesia assesment, Cardiology consultation, and Arrangement of Blood products was done. Informed written consent form pt was taken and was Shifted to OT for surgery
Pt was operated on 06th July 2023. first urology team did cystoscopy and Right sided Ureteroscopy. Pt was then handed over to surgical team after 3 way catheterisation. A standard midline laparotomy was done. small gut was examined from DJ flexure to IC junction, Gall bladder and cholecystoduodenal fistula were covered by dense omental adhesions and were not exposed. There were 2 gallstones 2 ft from Ileocecal juntion, 5-6 inches apart as seen in 2nd picture. There were 2 areas of pressure necrosis 4 ft from DJ flexure where stones seemed to be impacted before they travelled distally. It can be seen in 3rd picture with blue arrow.
A longitudinal entertomy was done at antimesenteric border, both stones were exracted. Enterotomy was closed transversally with single layer extramucosal interupted stitches with vicryl 3-0 secured with lambert stitches as second layer as seen in the third picture.
These are two stones extracted from small bowel. The 2 pressure necrotic areas were assessed and these were the sites of impending perforation, those were repaired with vicryl 3-0 in extramucosal fashion and secured with lambert stitches. After washing peritoneal cavity and placing and securing drain in the pelvis, abdomen was closed through standard procedure.
Pt was shifted to SICU postoperatively, extubated, cathetrized, with NGT in place. Pt was kept NPO TFO wih fluids adjusted accordingly. He had an uneventful course through out his post op stay. By POD 4 his NGT was removed and started on oral sips. On Day 5 Drain was removed. Pt was stable enough to be shifted to room on POD 5. He was advanced to liquid diet on POD 6 and soft diet on POD7. His foley catheter was removed and after smooth recovery patient was discharged on 14th July 2023, on POD 08
Assalam O alikum I am Dr Namerah Nasir, registrar surgery, here is the outline of our second part of presentation, well be discussing
Gallstone ileus is an infrequent complication of cholelithiasis and is defined as a mechanical intestinal obstruction due to impaction of one or more gallstones within the gastrointestinal tract. The term “ileus” is a misnomer, since the obstruction is a true mechanical phenomenon. Gallstone gastrointestinal obstruction would be an appropriate term. Gallstone ileus has shown a constant incidence of 30-35 cases/1 million admissions over a 45-year period[5]. This entity develops in 0.3%-0.5% of patients with cholelithiasis It constitutes the etiologic factor in less than 5% of cases of intestinal obstruction. More common in elderly pts. Accordingly to the predominance of female patients in gallstone disease, the majority of gallstone ileus patients correspond to the female gender, with variable percentages from 72%-90%.
Gallstone ileus is frequently preceded by an initial episode of acute cholecystitis. The inflammation in the gallbladder and surrounding structures leads to adhesion formation. The inflammation and pressure effect of the offending gallstone causes erosion through the gallbladder wall, leading to fistula formation between the gallbladder and the adjacent and adhered portion of the gastrointestinal tract, with further gallstone passage. As this was the case in our patient as well. Less commonly, a gallstone may enter the duodenum through the common bile duct and through a dilated papila of Vater.
The most frequent fistula occurs between the gallbladder and the duodenum, due to their proximity. The stomach, small bowel and the transverse portion of the colon may also be involved.. This process might be part of the natural history of Mirizzi syndrome.
Once within the duodenal, intestinal or gastric lumen, the gallstone usually proceeds distally and may pass spontaneously through the rectum, or it may become impacted and cause obstruction. Less commonly if the gallstone is in the stomach, proximal migration can occur and the gallstone may be vomited. The size of the gallstone, the site of fistula formation and bowel lumen will determine whether an impaction will occur. The majority of gallstones smaller than 2 to 2.5 cm may pass spontaneously through a normal gastrointestinal tract and will be excreted uneventfully in the stools he site of impaction can be almost in any portion of the gastrointestinal tract. If the gallstone enters the duodenum, the most common intestinal obstruction will be the terminal ileum and the ileocecal valve because of their relatively narrow lumen and potentially less active peristalsis. Less frequently, the gallstone may be impacted in the proximal ileum or in the jejunum, especially if the gallstone is large enough. Less common locations include the stomach and the duodenum (Bouveret’s syndrome)
Here we can see the most common site of obstruction is ileum/terminal ileum
Now coming to the clinical presentation, Patient presents with the history of prior biliary symptoms or no prior symptoms, as this was the case in our patient.
Gallstone ileus may be manifested as acute, intermittent or chronic episodes of gastrointestinal obstruction. Nausea, vomiting, crampy abdominal pain and variable distension are commonly present. The intermittent nature of pain and vomiting of proximal gastrointestinal material, later becoming dark and feculent is due to the “tumbling” gallstone advancement. Therefore, there may be intermittent partial or complete intestinal obstruction, with temporary advancement of the gallstone and relief of symptoms, until the gallstone either passes through the gastrointestinal tract or it definitively becomes impacted and complete intestinal obstruction ensues. The character of the vomitus is dependent on the obstruction location. When the gallstone is in the stomach or upper small intestine, the vomitus is mainly gastric content, becoming feculent when the ileum is obstructed.
Physical examination may be nonspecific. The patients are often acutely ill, with signs of dehydration, abdominal distension and tenderness with high-pitched bowel sounds and obstructive jaundice. Fever, toxicity and physical signs of peritonitis may be noted if perforation of the intestinal wall takes place. The exam may be completely normal if no obstruction is present at the moment
Baseline investigations may show deranged LFTs, raised TLC or any other abnormality depending upon the metabolic state of the patient.
Plain abdominal radiographs are of major importance in establishing the diagnosis. In 1941, Rigler et al[38] described four radiographic signs in gallstone ileus: (1) partial or complete intestinal obstruction; (2) pneumobilia or contrast material in the biliary tree; (3) an aberrant gallstone; and (4) change of the position of such gallstone on serial films. The presence of two of the three first signs, has been considered pathognomonic and has been found in 20%-50% of cases. Pneumobilia may occur secondary to prior surgical or endoscopic biliary interventions. Therefore, the clinical presentation should be considered when evaluating this radiologic sign
When diagnosis is still doubtful, an abdominal ultrasound (US) will be indicated for gallbladder stones, fistula and impacted gallstone visualization. It may also confirm the presence of choledocholithiasis. The combination of abdominal films and USG has increased the sensitivity of diagnosis of gallstone ileus to 74%.
Computed tomography (CT) is considered superior to plain abdominal films or US in the diagnosis of gallstone ileus cases, with a sensitivity of up to 93%. In a retrospective study by Lassandro et Al Rigler’s triad was observed in 77.8% of cases by means of CT, compared to 14.8% with radiographs and 11.1% with US. Bowel loops dilatation was seen in 92.6% of cases, pneumobilia in 88.9%, ectopic gallstone in 81.5%, air-fluid levels in 37%, and the bilio-digestive fistula in 14.8%.
Rigler's triad. (A) Axial CT of the upper abdomen which shows pneumobilia.(B) Dilated small bowell loops with an impacted gallstone. (C) Coronal view in which a gallbladder-duodenal fistula is noted.
Magnetic resonance cholangiopancreatography is modality of choice for investigation in biliary tree pathologies. In patients with gall stone ileus connection is delineated between gallbladder and gut . As you cann see here (A) Magnetic resonance cholangiopancreatography showing pneumobilia in gallbladder (white arrows). (B) Small bowel and fundus of gallbladder connected to each other (white arrows).
The main therapeutic goal is relief of intestinal obstruction by extraction of the offending gallstone. Fluid and electrolyte imbalances and metabolic derangements due to intestinal obstruction, delayed presentation and pre-existing co-morbidities are common, and require management prior to surgical intervention. Operating on unprepared patient, increases mortality and morbidity as compared to those who are build up before surgery.
Patients are given conservative trial first for relief of obstructon, if pt is hemodynamically stable with subacute intestinal obstruction. But if symptoms worsens or doesn’t resolve after 72 hours with confirmed diagnosis, open surgery has been the mainstay of treatment, more recently other approaches have been employed, including laparoscopic surgery Endoscopic removal of stones and lithotripsy, although too few cases have been reported to come to any conclusion as to the role of these newer approaches.
There is no consensus on the indicated surgical procedure. The current surgical procedures are: (1) simple enterolithotomy; (2) enterolithotomy, cholecystectomy and fistula closure (one-stage procedure); and (3) enterolithotomy with cholecystectomy performed later (two-stage procedure). Bowel resection is necessary in certain cases after enterolithotomy is performed. The main long-standing controversy in the management of gallstone ileus is whether biliary surgery should be carried out at the same time as the relief of obstruction of the bowel (one-stage procedure), performed later (two-stage procedure) or not at all.
Enterotomy at the anti-mesenteric border with extraction of the gallstone and transverse closure is the standard emergency management; cholecystectomy with resolution of the fistula in the same surgical act is reserved for young and clinically stable patients, when their conditions allow it, with two-step surgery with interval cholecystectomy being the most recommended approach in the majority of cases.
Based on a study in 1994, Reisner and Cohen9 indicated that despite mortality rate in simple stone extraction of 11.7%, one-stage surgery shows higher mortality rate of 16.9% with a higher level of invasiveness. Based on a study in 2014, Halabi et al1 reported significantly increased length of hospital stay and mortality rates in patients who underwent one-stage internal biliary fistula closure; for patients with ileus, one-stage surgery is excessively invasive, and associated postoperative complications are common. Two-stage surgery has a disadvantage of associated risk of recurrence, retrograde cholecystitis, and cancer development due to remaining cholecystointestinal fistula. Surgeons should consider these related issues as follows.
Effects of persistent cholecystointestinal fistula
Persistence of cholecysto intestinal fistula is a potential causal factor for retrograde cholecystitis or gallbladder cancer. The cholecystointestinal fistula remained untreated in 86.7% of cases of recurrent gallstone ileus, while cholecystectomy is necessary indication in patients with symptomatic gallstone. A total proportion of 11% of cholecystoduodenal fistula and 60% of cholecystocolonic fistula resulted in cholangitis,8 18 19 and 15% of cases of fistula showed complication of gallbladder cancer. Natural closure of cholecystointestinal fistula as a possible outcome
Natural fistula closure without treatment of the biliary - 61.5% of cases
Finally, the use of therapeutic endoscopy in this pathology is still under development.
Endoscopy is reserved for patients with Bouveret syndrome (upper endoscopy) or ileal or colonic obstruction (colonoscopy).Colonoscopic removal of impacted gallstones should be attempted in cases of colonic ileus. Second recent advancement is intralumenal fragmentation of stone then either these are passed sponatneously passed in stools or removed endoscopically.
Conclusions
In the treatment approach for cases of gallstone ileus, selection of surgical method should be based on the impaction site. Two-stage surgery is recommended for cases with impaction at the level of the small intestine, while one-stage surgery is recommended for cases with impaction at other sites. However, surgeons should judge the feasibility of one-stage surgery on the basis of the patient’s general condition.
