Gallstone ileus is a rare symptom of gallbladder disease. It is commonly seen in women and the elderly. It occurs when a stone causes a fistula between the gallbladder and the intestinal lumen. More than half of the patients had no history of biliary tract disease. Surgical intervention is still considered the best treatment option. However, the optimal choice between one-stage surgery and his two-stage surgery is still unknown. We present a case of gallstone ileus in a patient with rare epidemiological features. A 28-year-old male Hispanic patient with no history of gallbladder disease.
prologue
Biliary or gallstone ileus is a late complication of gallstone disease in which mechanical intestinal obstruction occurs due to the impact of one or more gallstones within the lumen of the gastrointestinal tract. [1]This happens when a stone causes a fistula between the gallbladder and the intestinal wall (most common in the duodenum) and is classified as a chronic fistula. [2]Obstruction in the duodenum has also been reported, but depending on the size of the stone, it may block the ileocecal valve. [3]It accounts for 1-4% of all bowel obstructions and occurs more frequently in the elderly (65 years and older) and women (72-90% of all cases). [2,3]Additionally, 50% of all patients presenting with gallstone ileus have a history of biliary tract disease. [3,4]This paper reports a case of gallstone ileus in a patient with rare epidemiological features.
case presentation
A 28-year-old Hispanic man presented to the emergency department with a 3-day history of generalized abdominal pain and vomiting. The pain was sudden, like colic. He confirmed that he had experienced constipation, bloating, and had not passed flatus in the past 5 days, and denied any comorbidities, abdominal surgery, cholelithiasis, or other significant medical history. The patient reported that he consumed alcohol for 5 consecutive days before the onset of symptoms and that he ate two high-fat meals in the last 2 days. He denied any history of abdominal pain or biliary symptoms prior to this event.On evaluation, the patient was hemodynamically stable and afebrile. A physical examination revealed a tender abdomen, mild mid-abdominal pain, and lower abdominal tenderness. Leukocytosis (white blood cell count, 21.4 × 10⁹/L), neutropenia (89.9%), hemoglobin level 18.3 g/dL, amylase level 106 u/L. The remaining parameters were unremarkable.A plain abdominal X-ray showed a radiopaque 3 cm × 3 cm density located in the lower abdomen and a dilated loop of the small intestine (Fig. 1).
Plain abdominal computed tomography confirmed small bowel obstruction and revealed an abrupt transition point corresponding to radiopaque stones in the ileum.No stones were observed in the gallbladder (Fig. 2 and figure 3).
Resuscitative measures were taken. Dehydration was managed using crystalloid fluid and gastrointestinal decompression was performed using a nasogastric tube. Analgesia and prophylactic antibiotics with third-generation cephalosporins were administered. The patient was ready for exploratory laparotomy. Intraoperative findings confirmed a large gallstone, 30 cm in size, in the ileocecal valve obstructing the lumen of the small intestine.Longitudinally he performed a 5 cm enterotomy and removed a 4 × 3 × 3 cm gallstone (Fig. Four and figure Five).
No partial enterectomy was required and the enterotomy was closed laterally. The postoperative course was uneventful. The patient recovered well and he was discharged 2 days after surgery. 14 days after the procedure and he was well followed up for 6 months.
discussion
The term gallstone ileus is a misnomer because the condition is a mechanical obstruction of the bowel and not a true ileus. Dr. Erasmus Bartholin, a Danish physician and mathematician, first described gallstone ileus in an autopsy in 1654. [5]Gallstone ileus is common in women and older people (over 60).Other risk factors include history of cholelithiasis, large stones (>2 cm), episodes of acute cholecystitis, and episodes of Caucasian ancestry [3,6]Our patient’s characteristics were not common for this pathology (young, male, thin, no history of symptoms, risk factors, or diagnosed with gallbladder disease). However, only his 50% of patients have a history of gallbladder disease. [7]To our knowledge, this is the second young patient reported with gallstone ileus. The youngest patient, she was a 13-year-old Japanese patient, reported in a study of her cohort of 112 patients published in 1980. [8-14] (table 1).
Optimal management of acute gallstone ileus remains controversial and can be divided into three subgroups: enterolithotomy alone, enterolithotomy, cholecystectomy, one-step procedure of fistula closure, and A two-step procedure of interval cholecystectomy and enterolithectomy with fistula closure [3,4]Simple enterolithectomy is safe, effective, and provides superior results to more invasive techniques.We recommend that this procedure be considered for patients with low surgical risk [15,16]Laparoscopic versus conventional approaches have not been studied.Leissner and Cohen [17] showed a higher mortality rate with a one-stage procedure compared with simple enterolithectomy. In the simple enterolithectomy group, his 15% of patients had residual biliary symptoms, of which only 10% required further surgery for symptom relief. The recurrence rate of gallstone ileus was less than 5% in the same group. In this case, enterolithotomy was chosen as the procedure and the patient made good progress. According to the literature, more than half of the cases show spontaneous fistula closure. [4]it was therefore decided not to address the patient’s fistula. In young patients without comorbidities, simple enterolithectomy can be considered an option. Surgeons should base their decisions on clinical judgment, expertise, and available resources.
Conclusion
Gallstone ileus is a rare complication of cholelithiasis and occurs most commonly in older female patients with a history of gallbladder disease. However, in recent years several reports have provided contrary data. Surgical intervention is still considered the best treatment option. However, the choice between simple enterolithectomy, one-stage surgery, and two-stage surgery remains controversial. Surgeons must determine the best treatment for each patient according to their expertise and available resources. Further research is needed to evaluate the best surgical treatment.
