NHÂN CA GALLSTONE ILEUS @ MEDIC

A 75-year-old woman was admitted to our hospital with a 3-week history of abdominal discomfort, vomiting and diarrhoea. On physical examination a non-generalized abdominal tenderness and distension was encountered. Laboratory findings revealed leukocytosis of 19.8 x 10^6/L. There was no deranged liver biochemistry. An abdominal contrast enhanced CT showed a thick walled, air-filled gall bladder, a distended stomach and dilated loops of small intestine (Fig.1). Although no gallstone could be identified, these findings suggested the presence of a cholecysto-enteric fistula and gallstone ileus. At laparotomy, three obstructive gallstones were removed from the ileum (Fig. 2). The gallbladder showed a thickened wall and pericystic inflammation. Considering the critically ill elderly patient, the gallbladder was left in place.

Recovery was initially uneventful. However, two months later the patient presented with general sickness, high fever (39°) and jaundice. The blood tests showed an inflammation, elevated liver enzymes and hyperbilirubinemia. The ERCP showed a slightly dilated common bile duct without an obvious obstructive gallstone. An endoprosthesis was placed and the patient showed some recovery. The fever however persisted and the clinical course deteriorated. A subcostal laparotomy was performed finding a firm gallbladder with malignant aspect. Various focal lesions were found in the liver of which intra-operative frozen sections confirmed the diagnosis of adenocarcinoma. Palliative treatment was started. As a result of a trend to early operative management of symptomatic cholecystolithiasis, late complications of long-standing cholecystitis such as gallstone ileus are becoming exceedingly rare. Controversy exists whether initial surgery for gallstone ileus should be a one-stage procedure including stone removal, cholecystectomy and closure of the bilioenteric fistula [1, 2], or should be limited to removal of obstructive stones [3]. Cholecystoduodenal fistula is the most common cause of gallstone ileus [4]. Gallstone ileus due to primary gallbladder carcinoma is even more infrequent. This case elevates the awareness for gallbladder carcinoma as an underlying cause for biliary-enteric fistula and subsequent gallstone ileus in 6% of the cases [5].

Jeroen Heemskerk (1), Simon W Nienhuijs (2)
Departments of Surgery,
(1) Laurentius Hospital Roermond; (2) Catharina Hospital Eindhoven, The Netherlands.

J Gastrointestin Liver Dis June 2009 Vol.18 No 2, 251-259