Gallstone ileus

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Classification according to ICD-10
K56 Paralytic ileus and mechanical ileus without a hernia
K56.3 Gallstone ileus
K80 Cholelithiasis
K80.0 Gallbladder stone with acute cholecystitis
K80.1 Gallbladder stone with other cholecystitis
ICD-10 online (WHO version 2019)

A gallstone is a rare complication of gallstone disease , wherein a from the bile ducts Disposed gallstone a bowel obstruction ( lat . Ileus triggers). Approx. 1 to 4% of all intestinal blockages are caused by a gallstone. Mostly older patients are affected.

causes

Gallstone disease can cause acute or chronic inflammation that not only affects the gallbladder, but also causes inflammation of the wall of the transverse intestine or duodenum that is anatomically close to the gallbladder . Instead of a breakdown of the gall bladder in the abdominal cavity, to a life-threatening bile peritonitis would result in the gall bladder wall may be perforated in the large intestine or the duodenum; a fistula develops . These fistulas are called cholecystocolic or cholecystoduodenal fistulas and, if they are chronic, often lead to a triad of symptoms of aerobilia (air in the biliary tract), chronic diarrhea and vitamin K deficiency. The intestinal obstruction occurs when a sufficiently large gallstone enters the intestine via this fistula that connects the gallbladder and the intestine. The occlusion is either in the area of ​​the fistula to the duodenum or transverse colon (caused by inflammatory walling of the stone with swelling of the surrounding tissue) or - if the stone has passed through the cholecystoduodenal fistula into the small intestine - at the transition from the small intestine to the large intestine, the so-called Ileo-caecal valve .

Diagnosis

Initially, patients often complain of abdominal pain and nausea. The imaging procedures show different findings depending on the location of the intestinal obstruction. Occasionally, air leaks into the biliary tract ( aerobilie ). The classic Rigler triad with ileus of the small intestine, aerobilia and evidence of gallstone at the ectopic site is rarely found in the X-ray overview image. Computed tomography shows the individual parts of the Triassic better.

High gallstone ileus

If the occlusion is in the area of ​​the duodenum , the symptoms of gastric outlet obstruction (also known as “high ileus” ) occur, ie vomiting of undigested stomach contents, resulting in high fluid loss and electrolyte changes . In the gastrointestinal passage , no contrast medium can be seen from the stomach or upper duodenum into the intestine. The occluding stone, the stenosing scarring, and occasionally the fistula in the gallbladder can be seen through a gastroscopy .

Ileus of the small intestine

If the stone causing the ileus is located in the area of ​​the ileocecal junction, the typical symptoms of the mechanical small intestinal ileus occur: vomiting of the small intestinal contents, cramp-like, moderate to severe abdominal pain, metallic sounding, increased intestinal noises during auscultation . Sonographically, one sees enlarged loops of the small intestine with disturbances in the transport of food (so-called “pendulum peristalsis” ) and a coarsened representation of the folds of the mucous membrane (“piano key phenomenon”) . The findings of all other imaging procedures as well as the laboratory findings also correspond to those of the mechanical ileus.

Colon ileus

If the occlusion is at the level of the transverse intestine (colon transversum) , the symptoms and objective findings develop somewhat more slowly due to the reservoir function of the large intestine, but they are similar to those in the small intestinal ileus. A colonic enema , which is usually carried out with water-soluble contrast medium instead of barium sulfate in such emergency situations , is a stop in the right upper abdomen without showing the right colonic flexure and the ascending colon.

therapy and progress

An untreated mechanical intestinal obstruction leads to reduced blood flow to the intestinal wall with subsequent gangrene ; there are severe electrolyte imbalances and the release of toxins , the mechanical ileus turns into a paralytic ileus when the intestine dies. This condition is incompatible with life.

Therefore, the care of the ileus is first priority. The surgical methods used depend on the location of the occlusion, the intraoperative findings and the patient's clinical condition. Whether bile cleansing should take place in the same surgical session or later is controversial in the scientific literature and very much depends on the individual case. Due to the small number of cases and the almost exclusively retrospectively recorded cases, a decision on this is difficult. Usually, a “one-stage procedure” is recommended for patients with a low surgical risk. The surgical treatment of the fistulas causing the disorder poses a particular problem, since in such cases a complicated and lengthy operation can be necessary.

Web links

Individual evidence

  1. ↑ a b A. A. Ayantunde, A. Agrawal: Gallstone ileus: diagnosis and management. In: World Journal of Surgery 2007 Jun; 31 (6), pp. 1292-1297. Epub 2007 Apr 15. PMID 17436117
  2. ^ A b A. Nakao, Y. Okamoto, M. Sunami, T. Fujita, T. Tsuji: The oldest patient with gallstone ileus: report of a case and review of 176 cases in Japan. In: Kurume Med J. 2008; 55 (1-2), pp. 29-33. PMID 18981682 .
  3. ↑ S. Savvidou, J. Goulis, A. Gantzarou, G. Ilonidis: Pneumobilia, chronic diarrhea, vitamin K malabsorption: a pathognomonic triad for cholecystocolonic fistulas. In: World J Gastroenterol. 2009 Aug 28; 15 (32), pp. 4077-4082. PMID 19705508 .
  4. ^ A b R. Costi, B. Randone, V. Violi, O. Scatton, L. Sarli, O. Soubrane, B. Dousset, T. Montariol: Cholecystocolonic fistula: facts and myths. A review of the 231 published cases. In: J Hepatobiliary Pancreat Surg. 2009; 16 (1), pp. 8-18. Epub 2008 Dec 17. PMID 19089311 .
  5. ↑ U. Schiemann, V. Dayyani, UG Müller-Lisse, M. Siebeck: Aerobilia as an initial sign of a cholecystoduodenal fistula - a case report. In: MMW Fortschr Med. 2004 Sep 2; 146 (35-36), pp. 39-40. PMID 15540538
  6. ^ JR Siewert, F. Harder, M. Rothmund: Practice of visceral surgery: Gastroenterological surgery. (at Googlebooks) Springer 2002, ISBN 3-540-65950-1 .
  7. ↑ J. Freyschmidt, St. Feuerbach (Ed.): Handbuch diagnostic radiology: Gastrointestinales System (at Googlebooks) Springer 2006, ISBN 3-540-41418-5 .
  8. ^ R. Ravikumar, JG Williams: The operative management of gallstone ileus. In: Ann R Coll Surg Engl. 2010 May; 92 (4), pp. 279-281. PMID 20501012 .