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• W1976460418 abstract "To the Editor: Gallstone ileus is a rare cause of mechanical bowel obstruction that can occur when an inflamed gallbladder adheres to adjacent bowel, forming a biliary-enteric fistula. Gallstones as a cause of mechanical bowel obstruction are found mainly in elderly women. This is a report of a 91-year-old woman with gallstone ileus and its treatment using laparoscopic enterotomy. A 91-year-old woman presented to the emergency department complaining of nausea and vomiting starting 3 days before, right after eating a sausage. She had not passed a stool for 3 days. She had recently had a pacemaker implanted; additional medical history was noncontributory. Physical examination of the abdomen showed a distended abdomen with normal bowel sounds. On palpation, the abdomen was soft but slightly tender, with no palpable masses. Signs of dehydration were present. There were no other relevant findings on physical examination. She was admitted for rehydration and observation. The night after admission, fecal vomiting was observed, and bowel sounds were absent. An abdominal radiograph showed dilated bowel loops with air–fluid levels characteristic of bowel obstruction and retrospectively a vague image of a giant stone in the inferior right abdominal quadrant. Computed tomography (CT) revealed a gallstone in the terminal ileum with some air in the biliary tract (Figure 1A). In retrospect, the patient stated that she had pain in the right upper abdomen several weeks before admission. Laparoscopic enterotomy with stone extraction was performed in a procedure without any complications. The extracted stone, measuring 2 by 6 cm, is depicted in Figure 1B. The day after the procedure, a postsurgical ileus occurred accompanied by delirium, which was treated with instructions for her to receive nothing by mouth, intravenous fluid repletion, enemas, and a single dose of haloperidol. Further recovery was uneventful. Gallstone ileus is a rare cause of mechanical bowel obstruction that can occur when an inflamed gallbladder adheres to adjacent bowel, forming a biliary-enteric fistula. After an episode of cholecystitis, pericholecystic inflammation can lead to the development of adhesions between the biliary and enteric tracts, where the gallstone causes fistula formation by pressure necrosis, a complication in 2% to 3% of all cases of cholelithiasis with associated cholecystitis.1 The gallstone must be at least 2 to 2.5 cm in diameter to cause obstruction.2 The most common site of stone impaction is the terminal ileum (60.5% of cases), but it can occur in any part of the bowel.3 According to reports from the 1990s, 1% to 4% of all cases of bowel obstruction are due to gallstones, although a recent review showed that, in the United States, gallstone ileus accounts for only 0.095% of cases of mechanical bowel obstruction.4 Gallstone ileus is a condition with a female predominance (4.5:1) that affects mainly the older population (mean age 77).3, 5 As a result of the stone tumbling through the bowel lumen, episodic obstruction occurs, and individuals present with intermittent symptoms of abdominal pain and nausea or vomiting. Because of the vague nature of these symptoms, diagnosis is often delayed by several days.3, 5 On plain abdominal radiography, findings include pneumobilia, intestinal obstruction, and an aberrantly located gallstone, also known as Rigler's triad.6 Abdominal CT scanning has an overall sensitivity of 93%, specificity of 100%, and diagnostic accuracy of 99%.7 Ultrasonography can aid diagnosis, but intestinal gas or absence of calcification of the stone can limit gallstone visualization.2 Adequate fluid repletion and relief of the obstruction are essential in the treatment of gallstone ileus. Although stones smaller than 2.5 cm can be managed conservatively, surgery is the cornerstone in the management of gallstone ileus. Several studies have assessed various surgical treatment options for this condition, but a clear consensus on the optimal surgical intervention has not been reached. Various treatment options include enterotomy with stone extraction alone; enterotomy with stone extraction, cholecystectomy, and fistula closure; bowel resection alone; and bowel resection with fistula closure.4 Considering that gallstone ileus affects mainly elderly adults with comorbidities, a less-invasive technique such as enterotomy with stone extraction alone is the preferred surgical treatment.4 Individuals can be managed using a wait-and-see policy after enterotomy alone because of a low recurrence rate.8 Cholecystectomy and bilioenteric fistula closure in a one-stage procedure should be reserved for low-risk individuals, preferentially in an elective setting.4 Gallstone ileus is a rare condition that can present with vague and intermittent symptoms. It should be considered in elderly women with symptoms of bowel obstruction, abdominal pain, and nausea or vomiting, especially when there is a history of gallstones or cholecystitis. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Heslinga, Bakker: writing of letter. van der Jagt-Willems, van Houtum: revision and critical review of content. Sponsor's Role: None." @default.
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• W1976460418 date "2014-08-01" @default.
• W1976460418 modified "2023-09-27" @default.
• W1976460418 title "Mechanical Bowel Obstruction Due to Occlusion with a Biliary Calculus: A Case of a 91-Year-Old Woman with Nausea and Vomiting" @default.
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• W1976460418 doi "https://doi.org/10.1111/jgs.12961" @default.
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