Gallstone Ileus Clinical features, Investigations and Treatment

Gallstone Ileus – Gallstone Obturation

 Gallstone ileus Introduction:

Gallstone ileus is more common in women and accounts for 1–4% of all presentations to hospital with small bowel obstruction. The term gallstone ileus is a misnomer,

As the condition is a mechanical obstruction of the gut and not a true ileus.

• It should be suspected in a patient who has gallstones and presents with intestinal obstruction.
• Elderly females above the age of 60 are usually affected.
• Gallstone reaches the terminal ileum by forming ‘cholecystoduodenal fistula’ due to recurrent attacks of cholecystitis.
• Due to recurrent inflammation, adhesions develop between gallbladder and duodenum (common) or gallbladder and colon or stomach (rare). Large stones cause pressure necrosis, resulting in formation of a cholecystoduodenal fistula.
• Terminal ileum is the narrowest portion of the gut wherein gallstone gets impacted. Sometimes, the stone may ulcerate from gallbladder into jejunum, colon, etc

 Gallstone ileus Clinical features

• They are suggestive of small intestinal obstruction—abdominal pain is severe, vomiting and distension.
• Step ladder peristalsis may be seen. History suggestive of recurrent cholecystitis may be present.

Rigler’s triad: Pneumobilia, the presence of an aberrant gallstone and enteric obstruction.

Bouveret syndrome: It is a gastric outlet syndrome secondary to stone lodged in proximal duodenum due to cholecystoduodenal fistula. Proximal migration of the stone will precipitate obstruction.

Gallstone ileus Investigations

1. Plain X-ray abdomen (erect position):

• May demonstrate multiple gas and fluid levels and stone in the gallbladder and also in the lower abdomen suggesting gallstone ileus.
• Air may be found1 in the biliary system.

2. Small bowel enema:

• May demonstrate partial obstruction.
• Computed tomography (CT) scanning is the investigation of choice. It has a preoperative diagnosis of gallstone ileus with a sensitivity of 93%.
• It will also indicate any inflammation of the gallbladder, fistula—air pockets in the gallbladder, distal stone and proximal dilatation.

3. Computed tomography (CT):

• CT Scanning is the investigation of choice. It has a preoperative diagnosis of gallstone ileus with a sensitivity of 93%.
• It will also indicate any inflammation of the gallbladder, fistula—air pockets in the gallbladder, distal stone and proximal dilatation.

 Gallstone ileus Treatment

• There is difference of opinion regarding what is the ideal surgery to be done in case of gallstone obstruction. It is because many patients are elderly, with co-morbidity and they have intestinal obstruction (dehydration, bowel oedema, bacterial proliferation, etc).
• Whatever it is, the first step is always to do enterolithotomy by incising the ileum and delivering the stone/stones.
• It may be possible to crush the stone and pass it onto caecum, avoiding enterolithotomy. Search the proximal intestine for any other stones.

What must be done next? Two types are described.

1. Single stage procedure: If general condition of the patient is good, and gallbladder is gangrenous or inflamed (more chances of perforation), enterolithotomy, cholecystectomy followed by closure of the duodenal fistula is done.
2. Two-stage procedure: If general condition is not good or with no active inflammation of the gallbladder, enterolithotomy is the procedure of choice, followed 6 weeks later by cholecystectomy with closure of the duodenal fistula

Mesenteric Vascular Occlusion Definition

Acute mesenteric ischaemia is an abrupt reduction in blood flow to the intestinal circulation of sufficient magnitude to compromise the metabolic requirements and potentially threaten the viability of the affected organs

Anatomy of Mesenteric Vasculature

• The mesenteric arterial and venous circulation of the abdominal viscera form an extensive vascular network.
• There are a large number of collateral pathways that protect against ischaemic changes.
• The three major branches of aorta responsible for the arterial supply of the intestine are: Coeliac artery supplies the foregut,  superior mesenteric artery (SMA) supplies midgut and inferior mesenteric artery supplies hindgut. The venous drainage includes the superior and inferior mesenteric vein.

Normal Anatomy and Variations

• Coeliac axis: Normal coeliac axis anatomy is seen in only 55% of patients. An anomalous right or left hepatic artery has been reported in about 50% of patients.
• Superior mesenteric artery: It supplies the entiresmall intestines and right one-third of the transverse colon.
• Inferior mesenteric artery (IMA): It supplies the left colon including rectum and surgical anal canal. The
• IMA arises at the level of the third lumbar vertebra supplies the large bowel from the mid-transverse colon to upper rectum. Several collateral networks exist in the branches of These collaterals are important when rectosigmoid or splenic flexure resection is performed;
• Collaterals: Like collaterals in the leg, many collaterals exist between 3 major branches—coeliac artery, SMA and IM Because of these extensive collaterals, patients remain asymptomatic with normal bowel function may have chronic occlusion of one or
  two mesenteric vessels.

Griffiths’ point: Between branches of left colic and SMA.

Sudeck point: Sigmoidal arteries and superior rectal vessels.

Mesenteric Vascular Occusion Types

1. Acute mesenteric ischaemia (AMI): It is a sudden occlusion of an artery or vein resulting in gangrene. It has a mortality rate of 60 to 90%.
2. Chronic mesenteric ischaemia (CMI): It is associated with stenosis of the coeliac artery, superior mesenteric artery or inferior mesenteric artery.
3.  NOMI: Non-occlusive mesenteric ischaemia

Mesenteric Vascular Occlusion Pathogenesis

1. Ischaemic damage to the intestine occurs with decreased blood supply to a level at which delivery of oxygen and various nutrients cannot maintain oxidative metabolism. ‘
2. Cell integrity is lost resulting in cell death. In low-flow states, blood is shunted from arterioles to venules near the base of the villus resulting in necrosis of the intestinal villi.

Non – Occlusive Mesenteric Ischaemia(NOMI)

It is a discrete clinical entity where mesenteric flow is impeded due to arterial spasm.

NOMI Causes

• Typically these patients are critically ill in intensive care units (ICU), intubated. The pathology resides in
• The mesenteric arcades where severe spasms have limited flow. Like AMI, they can have loose and bloody stools, and abdominal pain out of proportion to signs. Tenderness is present.
• Diagnostic arteriography is the only way to demonstrate the small vessel mesenteric arterial spasm that
  leads to NOMI.

NOMI Treatment

Direct catheter delivery of papaverine (30–60 mg/hour) may have to be given for a few days.

• Systemic anticoagulants are given. Vessel spasms can be overcome by maximizing cardiac output.
• Peritonitis or clinical evidence of bowel perforation mandates exploration and resection of the ischaemic segment. Also, the primary cause of acute illness is treated.

NOMI Etiology

• Pharmacotherapy
• Digoxin stress response
• Digitalis
• Cocaine
• Alpha agonists
• Vasopressin

Sympathetically mediated

• Hypovolaemia or haemorrhagic shock
• Haemodialysis
• Cardiopulmonary bypass
• CCF
• Arrhythmias
• Pancreatitis
• Septic shock
• End-stage renal disease

Chronic Mesenteric Ischaemia

It is a form of severe atherosclerotic disease affecting multiple mesenteric arteries. Most of patients are asymptomatic due to rich collateral network. The most common cause—is atherosclerosis. Other causes are vasculitides—Takayasu disease, and coarctation of the aorta.

Women are more commonly affected than men. When a patient is not eating, the circulatory demands of the resting bowel are easily met and there is no pain.

• After eating, in times of high demand, pain occurs.
• Hence called postprandial pain. Pain typically begins 15 to 45 minutes after eating and is described as crampy, affecting the upper and periumbilical abdomen. It is due to a phenomenon called the “Gastric steal” phenomenon.
• A metabolically active stomach “steals” from the splanchnic circulation. Fixed proximal arterial obstruction does not allow for blood volume to compensate. Small bowel ischaemia and pain follow.
• Patients develop an aversion to eating or “food fear” as the disease progresses.
• Over some time, significant weight loss occurs.
• Triad of CMI: Postprandial pain, food fear and weight loss.
• CT angiography is the investigation of choice.
• Endovascular therapy stenting and bypass grafts can be used. Endarterectomy can also be done if significant thrombus is present in the SMA.

Chronic Mesenteric Ischaemia Strictures

Common causes are tubercular stricture of the ileum or jejunum in

• India and Crohn’s disease in the Western world.
• Radiation stricture, ischaemic strictures and nonspecific strictures are the other causes.
• Malignant strictures.
• Carcinoma rectosigmoid junction tumours. Small bowel enema or enteroscopy are very useful investigations.

Stricture Causes

• Hirschsprung’s disease—congenital megacolon
• Atresia and stenosis
•  Arrested rotation with bands
• Volvulus neonatorum
• Meconium ileus
• Imperforate anus