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Gas in gallbladder—gallstone ileus?

Gas in gallbladder—gallstone ileus? Gallstone ileus is an uncommon presentation among acute surgical patients. Its diagnosis is often delayed due to its non- specific clinical presentation. We report the case of an 81-year-old gentleman with a 2-day history of small bowel obstruction (SBO). He had a history of gallstone disease and no past surgical history. Plain abdominal radiography was consistent with SBO. A computed tomography (CT) abdomen scan would be warranted given the presentation of SBO in a virgin abdomen. However, this case emphasizes the importance of early CT imaging in a case of suspected gallstone ileus given that the diagnosis could not be made on plain abdominal radiography. CT abdomen is superior in detecting small amounts of gas and at discriminating soft tissue density. X-ray showed dilated small bowel loops (Fig. 1), consistent with INTRODUCTION a developed SBO. Given the scenario of SBO in a virgin abdomen, Gallstone ileus is a rare entity, occurring in 0.3–0.5% of patients a computed tomography (CT) of abdomen was performed, which with cholelithiasis [1]. It is the cause of acute small bowel confirmed the diagnosis of SBO with the transition point being obstruction (SBO) in only 1% of cases [2]. Treatment is often at close proximity to the gallbladder. delayed due to delays in diagnosis. We present the diagnosis and Given that the patient was clinically well, he was managed management of a patient with acute SBO in a virgin abdomen. conservatively overnight with a nasogastric tube and intra- venous fluid therapy. The CT scan was closely reviewed by the surgical team the following day and noted the presence of CASE REPORT gas within the gallbladder, which was not commented upon An 81-year-old gentleman presented to the emergency depart- by the radiologist (Fig. 2). Furthermore, SBO transition point ment with a 2-day history of vomiting, central abdominal pain appeared to be in the distal ileum, where a 3-cm “soft tissue” and distension. He had no prior abdominal surgeries, but was mass was seen (Fig. 3). His previous CT scan that diagnosed his waiting for an elective cholecystectomy for chronic cholecystitis. chronic cholecystitis demonstrated a 3-cm gallstone within the On examination, his abdomen was distended, with mild central gallbladder, which was not seen on the current CT. The findings abdominal tenderness and no evidence of umbilical or groin of gas within the gallbladder in the setting of SBO and a mass hernia. Blood tests were unremarkable except for mild acute of similar size to the known gallstone raised the suspicion for kidney injury secondary to dehydration. His plain abdominal gallstone ileus. The patient then underwent a laparotomy and Received: June 27, 2019. Accepted: August 3, 2019 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2019. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com 1 Downloaded from https://academic.oup.com/jscr/article-abstract/2019/8/rjz243/5556291 by Ed 'DeepDyve' Gillespie user on 16 October 2019 2 S.W. Gan et al. Figure 1: dilated small bowel. Figure 4: 43-mm gallstone. DISCUSSION Gallstone ileus refers to a mechanical bowel obstruction due to gallstone impaction within the bowel. Despite improvements in imaging techniques, it remains a diagnostic challenge and is associated with a high degree of morbidity and mortality [1]. The clinical presentation is usually non-specific, and 30% of patients have no known cholelithiasis [3]. Patients present with acute or subacute obstructive symptoms including nausea, vomiting, dehydration and abdominal distention or pain. A small proportion may present with haematemesis due to duodenal erosions [2]. The symptoms may be intermit- tent as the calculus tumbles through the intestine causing intermittent obstruction. There is often a delay in seeking medical attention, and a further delay in diagnosis and treatment [4]. Gallstone ileus occurs when a large gallstone erodes through the gallbladder wall as a result of inflammation and pressure Figure 2: gas in the gallbladder. necrosis into the small bowel via a cholecystoenteric fistula [2]. Cholecystoduodenal fistula is the most common fistula type occurring in about 70% of patients due to the proximity of the duodenum, while cholecystocolonic and cholecystoduode- nocolonic fistulas account for 5%, respectively [1]. The majority of gallstones are impacted in the terminal ileum and ileocaecal valve due to narrow lumen and possibly less active peristalsis [2]. Larger gallstones are likely to be impacted in the proximal ileum or jejunum [1]. Less frequently, it may be impacted in the stomach, duodenum (causing Bouveret’s syndrome), Meckel’s diverticulum and colon [5]. Rigler’s triad in plain abdominal radiography of SBO, pneu- mobilia and ectopic gallstone within the bowel lumen is specific for gallstone ileus [6]. However, two out of three findings are seen in less than half of patients [5]. Pneumobilia occurs in 30– 60% of patients but is non-specific and may be caused by an incompetent sphincter of Oddi or prior biliary procedures [7]. Moreover, only one-fifth of gallstones are calcified sufficiently to be visible on plain radiography [8]. Abdominal ultrasound can visualize the gallbladder, fistula or the absence of a previously Figure 3: gallstone in distal ileum. visualized calculus in the gallbladder. The diagnostic sensitivity increases to 74% when both ultrasound and plain radiography are used [9]. In this scenario, this patient was known to have gallstones enterotomy for a 43-mm gallstone impacted in the distal ileum (Fig. 4). Apart from an episode of ileus, he made a full recovery and a virgin abdomen, so gallstone ileus was always a possibility. It was the finding of gas in the gallbladder on CT that prompted post-operatively and was discharged home, with an outpatient follow-up in the surgical clinic. the surgeons to consider the diagnosis. It is important to note Downloaded from https://academic.oup.com/jscr/article-abstract/2019/8/rjz243/5556291 by Ed 'DeepDyve' Gillespie user on 16 October 2019 Gas in gallbladder 3 that the diagnosis of gallstone ileus could not be made on and treatment approach. World J Gastrointest Surg plain abdominal radiography, despite the fact that the X-ray was 2016;8:65–76. consistent with SBO. This is due to very little air in the biliary tree 3. Riaz N, Khan MR, Tayeb M. Gallstone ileus: retrospective and only a small bubble in the gallbladder. The gallstone was not review of a single centre’s experience using two surgical calcified and appears of soft tissue density, and was invisible on procedures. Singapore Med J 2008;49:624–6. plain X-ray. Therefore, CT abdomen should be the investigation 4. Ayantunde AA, Agrawal A. Gallstone ileus: diagnosis and management. World J Surg 2007;31:1292–7. of choice for suspected gallstone ileus, due to superior sensitivity of CT to detect small amount of gas within the biliary tree and 5. Abou-Saif A, Al-Kawas FH. Complications of gallstone dis- ease: Mirizzi syndrome, cholecystocholedochal fistula, and to identify an intra-luminal foreign body of soft tissue density. gallstone ileus. Am J Gastroenterol 2002;97:249–54. Neither of these things is possible with plain radiology. 6. Rigler LG, Borman CN, Noble JF. Gallstone obstruction: pathogenesis and roentgen manifestations. JAMA 1941;117:1753–9. CONFLICT OF INTEREST 7. Reisner RM, Cohen JR. Gallstone ileus: a review of 1001 None declared. reported cases. Am Surg 1994;60:441–6. 8. Bortoff GA, Chen MY, Ott DJ, Wolfman NT, Routh WD. Gallbladder stones: imaging and intervention. Radiographics REFERENCES 2000;20:751–66. 1. Clavien PA, Richon J, Burgan S, Rohner A. Gallstone ileus. Br J 9. Ripollés T, Miguel-Dasit A, Errando J, Morote V, Gómez-Abril SA, Richart J. Gallstone ileus: increased diagnostic sensitiv- Surg 1990;77:737–42. ity by combining plain film and ultrasound. Abdom Imaging 2. Nuño-Guzmán CM, Marín-Contreras ME, Figueroa-Sánchez 2001;26:401–5. M, Corona JL. Gallstone ileus, clinical presentation, diagnostic http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Surgical Case Reports Oxford University Press

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Oxford University Press
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Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2019.
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2042-8812
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10.1093/jscr/rjz243
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Abstract

Gallstone ileus is an uncommon presentation among acute surgical patients. Its diagnosis is often delayed due to its non- specific clinical presentation. We report the case of an 81-year-old gentleman with a 2-day history of small bowel obstruction (SBO). He had a history of gallstone disease and no past surgical history. Plain abdominal radiography was consistent with SBO. A computed tomography (CT) abdomen scan would be warranted given the presentation of SBO in a virgin abdomen. However, this case emphasizes the importance of early CT imaging in a case of suspected gallstone ileus given that the diagnosis could not be made on plain abdominal radiography. CT abdomen is superior in detecting small amounts of gas and at discriminating soft tissue density. X-ray showed dilated small bowel loops (Fig. 1), consistent with INTRODUCTION a developed SBO. Given the scenario of SBO in a virgin abdomen, Gallstone ileus is a rare entity, occurring in 0.3–0.5% of patients a computed tomography (CT) of abdomen was performed, which with cholelithiasis [1]. It is the cause of acute small bowel confirmed the diagnosis of SBO with the transition point being obstruction (SBO) in only 1% of cases [2]. Treatment is often at close proximity to the gallbladder. delayed due to delays in diagnosis. We present the diagnosis and Given that the patient was clinically well, he was managed management of a patient with acute SBO in a virgin abdomen. conservatively overnight with a nasogastric tube and intra- venous fluid therapy. The CT scan was closely reviewed by the surgical team the following day and noted the presence of CASE REPORT gas within the gallbladder, which was not commented upon An 81-year-old gentleman presented to the emergency depart- by the radiologist (Fig. 2). Furthermore, SBO transition point ment with a 2-day history of vomiting, central abdominal pain appeared to be in the distal ileum, where a 3-cm “soft tissue” and distension. He had no prior abdominal surgeries, but was mass was seen (Fig. 3). His previous CT scan that diagnosed his waiting for an elective cholecystectomy for chronic cholecystitis. chronic cholecystitis demonstrated a 3-cm gallstone within the On examination, his abdomen was distended, with mild central gallbladder, which was not seen on the current CT. The findings abdominal tenderness and no evidence of umbilical or groin of gas within the gallbladder in the setting of SBO and a mass hernia. Blood tests were unremarkable except for mild acute of similar size to the known gallstone raised the suspicion for kidney injury secondary to dehydration. His plain abdominal gallstone ileus. The patient then underwent a laparotomy and Received: June 27, 2019. Accepted: August 3, 2019 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2019. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com 1 Downloaded from https://academic.oup.com/jscr/article-abstract/2019/8/rjz243/5556291 by Ed 'DeepDyve' Gillespie user on 16 October 2019 2 S.W. Gan et al. Figure 1: dilated small bowel. Figure 4: 43-mm gallstone. DISCUSSION Gallstone ileus refers to a mechanical bowel obstruction due to gallstone impaction within the bowel. Despite improvements in imaging techniques, it remains a diagnostic challenge and is associated with a high degree of morbidity and mortality [1]. The clinical presentation is usually non-specific, and 30% of patients have no known cholelithiasis [3]. Patients present with acute or subacute obstructive symptoms including nausea, vomiting, dehydration and abdominal distention or pain. A small proportion may present with haematemesis due to duodenal erosions [2]. The symptoms may be intermit- tent as the calculus tumbles through the intestine causing intermittent obstruction. There is often a delay in seeking medical attention, and a further delay in diagnosis and treatment [4]. Gallstone ileus occurs when a large gallstone erodes through the gallbladder wall as a result of inflammation and pressure Figure 2: gas in the gallbladder. necrosis into the small bowel via a cholecystoenteric fistula [2]. Cholecystoduodenal fistula is the most common fistula type occurring in about 70% of patients due to the proximity of the duodenum, while cholecystocolonic and cholecystoduode- nocolonic fistulas account for 5%, respectively [1]. The majority of gallstones are impacted in the terminal ileum and ileocaecal valve due to narrow lumen and possibly less active peristalsis [2]. Larger gallstones are likely to be impacted in the proximal ileum or jejunum [1]. Less frequently, it may be impacted in the stomach, duodenum (causing Bouveret’s syndrome), Meckel’s diverticulum and colon [5]. Rigler’s triad in plain abdominal radiography of SBO, pneu- mobilia and ectopic gallstone within the bowel lumen is specific for gallstone ileus [6]. However, two out of three findings are seen in less than half of patients [5]. Pneumobilia occurs in 30– 60% of patients but is non-specific and may be caused by an incompetent sphincter of Oddi or prior biliary procedures [7]. Moreover, only one-fifth of gallstones are calcified sufficiently to be visible on plain radiography [8]. Abdominal ultrasound can visualize the gallbladder, fistula or the absence of a previously Figure 3: gallstone in distal ileum. visualized calculus in the gallbladder. The diagnostic sensitivity increases to 74% when both ultrasound and plain radiography are used [9]. In this scenario, this patient was known to have gallstones enterotomy for a 43-mm gallstone impacted in the distal ileum (Fig. 4). Apart from an episode of ileus, he made a full recovery and a virgin abdomen, so gallstone ileus was always a possibility. It was the finding of gas in the gallbladder on CT that prompted post-operatively and was discharged home, with an outpatient follow-up in the surgical clinic. the surgeons to consider the diagnosis. It is important to note Downloaded from https://academic.oup.com/jscr/article-abstract/2019/8/rjz243/5556291 by Ed 'DeepDyve' Gillespie user on 16 October 2019 Gas in gallbladder 3 that the diagnosis of gallstone ileus could not be made on and treatment approach. World J Gastrointest Surg plain abdominal radiography, despite the fact that the X-ray was 2016;8:65–76. consistent with SBO. This is due to very little air in the biliary tree 3. Riaz N, Khan MR, Tayeb M. Gallstone ileus: retrospective and only a small bubble in the gallbladder. The gallstone was not review of a single centre’s experience using two surgical calcified and appears of soft tissue density, and was invisible on procedures. Singapore Med J 2008;49:624–6. plain X-ray. Therefore, CT abdomen should be the investigation 4. Ayantunde AA, Agrawal A. Gallstone ileus: diagnosis and management. World J Surg 2007;31:1292–7. of choice for suspected gallstone ileus, due to superior sensitivity of CT to detect small amount of gas within the biliary tree and 5. Abou-Saif A, Al-Kawas FH. Complications of gallstone dis- ease: Mirizzi syndrome, cholecystocholedochal fistula, and to identify an intra-luminal foreign body of soft tissue density. gallstone ileus. Am J Gastroenterol 2002;97:249–54. Neither of these things is possible with plain radiology. 6. Rigler LG, Borman CN, Noble JF. Gallstone obstruction: pathogenesis and roentgen manifestations. JAMA 1941;117:1753–9. CONFLICT OF INTEREST 7. Reisner RM, Cohen JR. Gallstone ileus: a review of 1001 None declared. reported cases. Am Surg 1994;60:441–6. 8. Bortoff GA, Chen MY, Ott DJ, Wolfman NT, Routh WD. Gallbladder stones: imaging and intervention. Radiographics REFERENCES 2000;20:751–66. 1. Clavien PA, Richon J, Burgan S, Rohner A. Gallstone ileus. Br J 9. Ripollés T, Miguel-Dasit A, Errando J, Morote V, Gómez-Abril SA, Richart J. Gallstone ileus: increased diagnostic sensitiv- Surg 1990;77:737–42. ity by combining plain film and ultrasound. Abdom Imaging 2. Nuño-Guzmán CM, Marín-Contreras ME, Figueroa-Sánchez 2001;26:401–5. M, Corona JL. Gallstone ileus, clinical presentation, diagnostic

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Journal of Surgical Case ReportsOxford University Press

Published: Aug 1, 2019

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