38 Annals of Cancer Research and Therapy Vol. 25 No. 1, 2017

Ann. Cancer Res. Ther. Vol. 25, No. 1, pp. 38-40, 2017

Introduction

Gallstone ileus is a rare and potentially life-threaten-ing manifestation of cholelithiasis. The gallstone enters the enteric lumen through a biliary-enteric fistula and impaction of the stone causes ileus. According to the literature, this condition mainly occurs in older women, and its treatment is accompanied by a significant amount of morbidity and mortality1, 2).

Surgical intervention has been considered the main-stay of treatment, although the addition of cholecystec-tomy to the emergency enterolithotomy (removal of the stone after enterotomy) at the initial operation is con-troversial2-4). Alternatively, conservative therapy can be chosen because spontaneous resolution of gallstone ileus or successful endoscopic treatment has been increasingly reported5-9). If conservative treatment is highly effective, it would be attractive, since older patients often have severe comorbid disease which compromises the postop-

erative course8). However, the exact prediction of sponta-neous evacuation of gallstones remains difficult.

In this case report, we describe a patient with gall-stone ileus. Although conservative treatment was initially attempted, enterolithotomy was eventually performed due to delayed evacuation of the stone.

Case presentation

A 61-year-old woman was referred to our hospital for three days of appetite loss and intermittent vomiting. She was on medication for psychiatric symptoms for several years. Her blood test revealed elevated levels of serum creatine phosphokinase (3066 U/L; normal range, 43-165 U/L), white blood cells (10.2 × 103/μL; normal range, 41-93 × 103/μL), C-reactive protein (26.6 mg/dL; normal range, 0-0.3 mg/dL), and serum creatinine (10.64 mg/dL; normal range, 0.047-0.79 mg/dL).

Abdominal computed tomography (CT) scans revealed a distended upper gastrointestinal tract and impaction with an oval mass in the jejunum (Fig. 1A). The center of the mass was of high density, surrounded by alternating layers of low and high density material. The longitudinal

Lessons learnt from a case of enterolithotomy for gallstone ileus of the jejunum

Toshichika Kanagawa1), Hiromichi Maeda2), Ken Okamoto2), Yoichi Ishikawa1), Toyokazu Akimori1), Norihito Kamioka1), Takashi Usui3), Tsutomu Namikawa4), Kazuhiro Hanazaki4), Michiya Kobayashi2)

1) Kochi Prefectural Hata Kenmin Hospital, 2) Cancer Treatment Center, Kochi Medical School Hospital, 3) Tano Hospital, 4) Depatment of Surgery, Kochi Medical School, Kochi University

AbstractBackground: Gallstone impaction, which is the result of gallstone migration into the digestive tract through a biliary-enteric fistula, is a well-known but rare cause of mechanical ileus. In this report, we describe an interesting case of gallstone ileus, in which surgical intervention was eventually necessary due to a delay in stone evacuation, and spontaneous closure of the biliary-enteric fistula occurred early after enterolithotomy.Case presentation: A 61-year-old woman was referred to our hospital for the treatment of vomiting. Computed tomography revealed a distended upper gastrointestinal tract, pneumobilia, and impaction with an oval mass measuring 3.2 × 2.5 cm in size within the intestinal lumen, leading to a diagnosis of gallstone ileus. The patient was initially treated conservatively with volume resuscitation, continuous hemodialysis for acute renal failure, and an ileus tube. Although the patient’s condi-tion improved, evacuation of the stone was not observed 5 days after admission. The patient then underwent enterolithotomy and the initial diagnosis was confirmed surgically. The postoperative course was uneventful and follow-up endoscopy revealed spontaneous closure of the biliary-enteric fistula.Conclusion: Spontaneous resolution of gallstone ileus after conservative treatment has been increasingly reported. However, our experience suggests that swift transition to surgical intervention is necessary when conservative treatment is not effec-tive. Although spontaneous closure of the fistula may occur early after enterolithotomy, long term result, including cancer development, remains unknown.

Keywords: gallstone ileus, spontaneous closure, biliary-enteric fistula

(Received June 2, 2017; Accepted June 20, 2017)

Correspondence to : Hiromichi Maeda, MD, PhD. Cancer Treatment Center, Kochi Medical School Hospital, Kohasu, Oko-cho, Nankoku-city, Kochi, 783-8505, Japan. Tel: +81-88-880-2182, Fax: +81-88-880-2183, E-mail; hmaeda@kochi-u.ac.jp

39gallstone ileus

and transverse diameters of the mass were 32 mm and 25 mm, respectively. CT scans also revealed pneumobilia and a fistula between the gallbladder and the duodenum (Fig. 1B), which was confirmed by upper gastrointestinal endoscopy examination (Fig. 1C). The patient was diag-nosed with gallstone ileus, dehydration due to ileus, con-sequent acute prerenal renal failure, and severe intestinal infection. The patient was initially treated conservatively with an ileus tube, hydration via intravenous infusion, antibiotic therapy, and continuous hemodialysis in the intensive care unit.

After 5 days of intensive treatment, the patient’s gener-al condition improved dramatically. However, repeat CT scans revealed that the gallstone remained within the je-junum, although the stone had moved slightly to the anal side of its original position. The patient underwent an exploratory laparotomy with a midline incision and the small intestine at the obstruction was exteriorized. An enterolithotomy was performed with a vertical incision, and closed with transverse sutures of the small intestine.

The operation time was 53 min, and there was minimal blood loss. The postoperative course was uneventful and follow-up endoscopy 10 days after the operation revealed that the fistula had spontaneously closed (Fig. 1D). The patient was discharged 19 days after the operation, under close observation for the recurrence of cholelithiasis.

Discussion

Gallstone ileus is a rare condition, which predomi-nantly affects older women. A study stated that only 0.095% of cases of mechanical bowel obstruction are caused by gallstone ileus in the United States1), which is much lower than previously reported10, 11). This decline in the frequency of gallstone ileus may be due to the in-creased number of laparoscopic cholecystectomies that are now performed1). Another possible explanation is that conservative treatment may be chosen more frequently than before. Indeed, recent reports suggest the majority of cases now undergo spontaneous stone evacuation or

Fig. 1 Radiological and endoscopic examination and treatment(A) Abdominal computed tomography images revealed an oval mass within the small bowel. The inside of the mass was of low density, while the outside was of high density. The mass completely blocked the flow of the luminal content. (B) A fistula between the gallbladder and the duodenum was obvious. (C) Upper gastrointestinal endoscopy revealed a fistula between the gallbladder and the duodenum. An ileus tube was introduced using endoscopy guidance. (D) Spontaneous closure of fistula was observed 10 days after operation.

40 Annals of Cancer Research and Therapy Vol. 25 No. 1, 2017

endoscopic treatment5-9). The precise diagnosis of gall-stone ileus using modern diagnostic radiology might have accelerated this trend. Besides, conservative management to avoid surgery is preferred, especially in older patients who often have severe comorbidities8).

In our patient, gallstone ileus was accompanied by severe dehydration, acute renal failure, and enteritis. As such, surgical treatment was considered too invasive, leading to the initiation of conservative treatment with an ileus tube, volume resuscitation and continuous renal replacement therapy. However, repeat CT scans revealed the gallstone remaining in the jejunum, and so enteroli-thotomy was performed instead of continuing conserva-tive treatment. Thus this case presents two important clinical lessons: first, occasionally spontaneous evacua-tion of larger stones doesn’t occur although it is an attrac-tive management strategy; and second, prompt transition to surgical intervention should be considered in similar cases.

The rate of spontaneous resolution of gallstone il-eus by conservative treatment is unclear. A review of reported cases suggested that the spontaneous evacua-tion of gallstones only occurs in around 1% of cases11). Another review of recurrent gallstone ileus demonstrated a 4.9% success rate for conservative treatment at the first episode of gallstone ileus12), while reports suggest 7%-14% of reported episodes of gallstone ileus in Japan are treated without surgery13, 14). Gallstones less than 2 cm in size are more likely to be successfully treated conser-vatively. However, a review of recently reported cases showed spontaneous evacuation of larger stones (diameter greater than 2.5 cm)8). Estimating the rate of spontaneous evacuation is generally compromised by a number of bi-ases, discrepancies and differences among reports. Thus, predicting the results of conservative treatment in each patient is still difficult, and treatment could vary signifi-cantly among institutes and/or countries. Therefore, a systematic survey of the efficacy of conservative therapy is necessary to decide whether a patient should promptly undergo surgical intervention after resuscitation, or first attempt conservative treatment.

The spontaneous closure of a biliary-enteric fistula early after enterolithotomy has been rarely reported15). Theoretically, a biliary-enteric fistula may be associated with retrograde cholangitis or the development of malig-nancy as a result of chronic inflammation. Spontaneous closure of the fistula means that a delayed elective cho-lecystectomy can be avoided15), however, closure of the fistula may result in the future development of another gallstone and/or recurrent gallstone ileus. The long-term consequences of spontaneous fistula closure remain un-clear, and thus we decided that close observation of the biliary tract was mandatory in our patient. The accumu-

lation of similar reports in the literature will be neces-sary to fully understand this condition.

In conclusion, predicting the spontaneous resolution of gallstone ileus remains difficult. When conservative therapy is chosen, repetitive evaluation of the impacted stone is essential in order to shorten the hospital stay and precisely time any surgical intervention that may be re-quired. After enterolithotomy, spontaneous closure of the biliary-enteric fistula can be observed with endoscopic examination. However, more experience is necessary to understand the long-term consequences of spontaneous closure, including cancer development.

Conflict of interest: There is no conflict of interest to declare.

Financial support: None

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