Gallstone ileus. A case treated with minilaparotomy and a review of the literature.

Abstract:

:Gallstone ileus is a rare complication of cholelithiasis which occurs in less than 1% of patients and is the cause of 1- 4% of cases of small bowel obstruction. The pathogenesis involves the formation of a bilioenteric fistula. We report the case of gallstone ileus in an 81-year old woman with typical abdominal pain, arterial hypertension and coronary artery disease. An abdominal computed tomography (CT) scan showed pneumobilia, dilated loops of small bowel and an ectopic gallstone obstructing the intestinal lumen. The patient underwent enterolithotomy and a 5-cm stone 20 cm from the ileocecal valve was removed. In the literature enterolithotomy alone is the procedure most frequently used for gallstone ileus. Enterolithotomy plus cholecystectomy and/or fistulectomy is only indicated in selected patients. The clinical signs and symptoms depend on the site of the obstruction and usually include abdominal pain, nausea and vomiting. The diagnostic test of choice is an abdominal CT scan. KEY WORDS:Cholecystoenteric fistula, Gallstone ileus, Minilaparotomy. :Gli Autori presentano un caso di ileo biliare, osservato in una donna di 81 anni con sintomatologia addominale tipica, perdurante da circa sette giorni con ipertensione arteriosa e cardiopatia ischemica. L’esame TC dimostrava la presenza di aerobilia, dilatazione delle anse intestinali e calcolo ostruente in sede ectopica. Non si riteneva opportuno trattare la fistola bilio-enterica in prima istanza sia per le condizioni generali della paziente, compromesse da storia di sette giorni di occlusione intestinale, sia per la situazione anatomica locale. Si procedeva pertanto ad una minilaparotomia con incisione alla McBurney . Si esaminava tutto l’ileo fino al legamento del Treitz per escludere la presenza di altri calcoli. Si estrinsecava il tratto di ileo contenente il calcolo e si procedeva a dislocare il calcolo a monte nel tratto dilatato onde evitare di effettuare la enterolitotomia nel tratto sofferente. Veniva quindi praticata l’enterotomia con estrazione del calcolo La terapia è chirurgica se si escludono i rari casi in cui il calcolo viene eliminato spontaneamente o si riesce ad estrarlo per via endoscopica nel caso abbia una localizzazione piloro-duodenale. Il problema più dibattuto è sicuramente rappresentato dagli orientamenti non univoci in tema di tattica operatoria, e cioè se sia più corretto trattare contemporaneamente l’ostruzione e la fistola biliare (one stage) oppure effettuare la correzione della fistola in un secondo momento (trattamento in due tempi) o non correggerla affatto. L’enterolitotomia semplice rappresenta il 73% di tutti gli interventi per ileo biliare e ciò perché l’ileo biliare colpisce prevalentemente pazienti con età avanzata e gravi patologie associate spesso con squilibri metabolici al momento dell’intervento chirurgico. In accordo con la maggior parte degli autori, sembra che l’approccio più razionale sia rappresentato da un intervento chirurgico di minima, anche con minilaparotomia, come nel nostro caso, volto a risolvere l’occlusione intestinale astenendosi da atti chirurgici potenzialmente dannosi in presenza di estese e tenaci aderenze infiammatorie.

journal_name

Ann Ital Chir

authors

Zappia F,Petracca G,Talarico CA

subject

Has Abstract

pub_date

2017-03-29 00:00:00

eissn

0003-469X

issn

2239-253X

pii

S2239253X1702535X

journal_volume

6

pub_type

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