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SPONTANEOUS biliary fistulae are probably not as rare as is generally supposed. Before the advent of the roentgen ray, clinical diagnosis of this condition was rarely made. Moller (1), quoted by G. A. Moore, states that out of 22 cases of gallstone ileus which he operated upon, the correct diagnosis was made in three cases. Courvoisier (2) states that about 4 per cent of his cases of intestinal obstruction from all causes were due to gallstones. Powers (3) found four cases, or 2.2 per cent, in 179 operations for intestinal obstruction. Kehr (4) found 100 fistulae, or about 5 per cent, in 2,000 gall-bladder operations. Since roentgen-ray examinations have come into general use, diagnoses of biliary fistulae have been more frequent. In 1933, Firor (5) collected 40 odd cases from the roentgen literature. As the writer has seen four cases in one small hospital, there appears to be no question but that many times this number have been unreported. Firor credits Busic with having made the first roentgen diagnosis i...

Summary A case of intermittent gallstone ileus of at least six years' duration is presented. Prior cholecystectomy, absence of roentgen findings of biliary fistula, and the unusually long duration of the complaint complicated the diagnosis.

There are many communications in the literature describing gallstone or biliary ileus. In the period 1941 to 1950 88 papers on this subject were published. The majority of these are isolated case reports and few deal solely with the. radiographic diagnosis. Two factors serve to re-alert roentgenologists to an understanding and diagnosis of gallstone ileus. One is the high mortality of the disease; the other is the number of reports of gallstone obstruction from the surgical point of view which fail to mention the roentgen findings. As recently as 1950 a report (1) of 7 cases in which gallstone ileus was found at operation stated that “the roentgenographic examination appears to be of little value.” None of these cases were diagnosed before surgery. Denneen and Broderick (2) reported 1 case in a series of 10 which was recognized preoperatively. The present paper is based upon 8 cases in which the diagnosis was made or suggested prior to surgery or death. Four of these will be reported in some detail. In th...

Der G.I. ist eine ernste Spatkomplikation des Gallensteinleidens mit einer Sterblichkeit von 29,4% bei 864 Fallen in 78 Arbeiten der Jahre 1955 bis 1968. In etwa 5% ist mit einem Rezidiv durch im Darm zuruck gelassene oder aus der G.Bl. nachwandernde Steine zu rechnen. Einschlieslich der eigenen 2 fanden wir 70 Rezidive mit einer Mortalitat von 21,4%. Das fruhe Rezidiv im unmittelbaren postoperativen Verlauf ist mit hoher Sterblichkeit belastet (50%). Bei der Operation mus daher der gesamte Darm ober- und unterhalb der Einklemmung auf weitere Steine und Darmwandschaden abgesucht werden. Das haufigere spate Rezidiv nach Monaten oder sogar Jahren hat eine gunstigere Prognose.

A recommendation is made for the use of therapeutic colonic and ileal distention with thin barium as a therapeutic measure in a patient presenting with gallstone ileus. Two cases treated successfully by this method are included.

In a consideration of the current problems in the surgical treatment of biliary tract disease it has been emphasized that greater attention should be directed to diagnosis. The demonstration of gallstones or the failure of the gallbladder to be visualized by cholecystography does not exclude other conditions that may be the cause of the patient's symptoms. Common duct stones are one of the causes of the persistence or recurrence of symptoms following cholecystectomy. Intravenous cholangiography in those patients with a history indicative of or compatible with choledocholithiasis is suggested as an aid in securing evidence for exploration of the common duct in conjunction with cholecystectomy. Long-standing biliary tract disease is associated with many complications rarely or never seen in youth. Some of these, if unrecognized and as a result not treated, often end fatally. Biliary enteric fistula formation with gallstone ileus is an example. Its diagnosis and management is discussed as a condition that may be seen with increasing frequency as the old age fraction of our population increases. For the geriatric group data are presented that focus attention upon the need for precision management of patients undergoing surgical treatment for biliary tract disease. A realization of the hazards inherent in those individuals sixty-five years of age and over because of deficient function in one or more of the principal organs or systems should result in the preoperative preparation and exercising of caution in embarking upon therapeutic surgical procedures. Injury to the common duct in the course of the performance of cholecystectomy may be followed by consequences far more detrimental to the patient than the ordinary course of gallbladder disease. The technical steps believed to be most important in avoiding such inadvertent injury are presented in the description of retrograde cholecystectomy. Because biliary tract disease occurs in individuals of all ages and varies so much in its course, often giving rise to serious complications, it is looked upon by many as a complicated and somewhat confusing clinical condition. In an attempt to facilitate the recognition of the disease in any of its various stages, phases and associated developments, a simple classification for descriptive purposes is presented. This is based upon the morphology and course of disease rather than upon the grouping of patients according to age, sex or physical habitus.

Summary 1.Recurrent cholelithic intestinal obstruction is a rare condition and like its counterpart, primary gallstone intestinal obstruction, has a very high mortality rate. 2.Earlier preoperative diagnosis would facilitate the reduction of this rate in all cases of gallstone ileus. Aids in reaching the correct diagnosis are: (a) careful inquiry into the past history for gall bladder symptomatology; (b) serious consideration of gallstones in the differential diagnosis of intestinal obstruction; (c) more frequent recourse to radiographic studies, with no hesitation in the use of contrast media if flat plate films are not helpful; (d) close scrutiny of the roentgenograms for the diagnostic criteria of internal biliary fistula and gallstone ileus. 3.The exercise of certain prophylactic surgical procedures at the time of the operation for the first cholelithic obstruction might prevent recurrent obstruction of this type. 4.A case of recurrent intestinal obstruction due to gallstone—the fourteenth in the literature—is presented.

The subject of duodenal fistula has been reviewed. During a fifteen-year period at Charity Hospital and Touro Infirmary, New Orleans, Louisiana, forty-three duodenal fistulas were recorded with a 37.2 per cent mortality. Four deaths occurred in twenty-one internal fistulas and twelve deaths in twenty-two external fistulas. There was a 66.6 per cent mortality in the end type of external fistula. The average onset of the end type of fistula was eight days after surgery. This type occurred more frequently in men. There was a 40 per cent mortality in the lateral type of external fistula. The average onset of the lateral type was five days after surgery. No sex preponderance was noted in this type. Interruption of intestinal continuity produced by external duodenal fistula leads to loss of contents and destruction of the abdominal wall. Adequate replacement of fluids and electrolytes and constant removal of drainage from the fistula by suction are important considerations in the care of these patients. Internal duodenal fistulas often communicate with the gallbladder. Rarer is the choledochoduodenal fistula which usually arises from duodenal ulcer which perforates onto the common duct. Most duodenocolic fistulas are due to carcinoma. Slightly less frequent in causation is duodenal ulcer. The demonstration of duodenocolic fistula is best accomplished by barium enema. The treatment of malignant duodenocolic fistula is radical resection in one or two stages, and duodenocolic fistula due to benign ulcer, subtotal gastrectomy and closure of colonic opening. Regurgitation of duodenal contents into the common duct is ordinarily prevented by the oblique course of the common duct through the pancreas and duodenal wall, the valve-like folds in the ampulla of Vater and the sphincter of Oddi. The presence of air in the biliary tract is of great value in diagnosis of patients who are seen for the first time during the phase of intestinal obstruction since gallstone ileus usually has its beginning with a duodenobiliary communication. The possibility of developing an abnormal communication between the biliary tract and duodenum due to biliary tract disease is a strong argument for removal of the gallbladder in all cases of cholelithiasis. Once the fistula is present, it must be attacked, the opening in the bowel closed, gallbladder removed and the common duct explored. Five case reports of choledochoduodenal fistula complicating duodenal ulcer are presented. There is a twofold problem in the management of this condition: to rid the patient of his fistula and to cure him of his ulcer. The preferred method of handling the fistula would appear to be reimplantation of the common duct into the duodenum or jejunum, and subtotal gastrectomy combined with vagotomy.

Colonic gallstone is an uncommon entity with a high morbidity and mortality due to various reasons. It remains a diagnostic challenge because of delayed and non-specific presentations, especially in the elderly population, often with multiple co-morbidities. We present a case of colonic gallstone ileus with spontaneous evacuation in a 67 years female who had a threeday history of intermittent bouts of colicky abdominal pain, vomiting , constipation and progressive abdominal distension, features of large bowel obstruction treated non operatively for 72 hours and passage of the stone spontaneously. Keywords: gallstone ileus; large bowel obstruction; colonic gallstone DOI: 10.3126/hren.v9i1.4363Health Renaissance, 2011: Vol.9 No.1:47-49

I NTESTINAL OBSTRUCTION secondary to gallstones is no longer considered a rare complication of cholelithiasis and cholecystitis. However, the occurrence of a fistulous communicatioin between the gallbladder and pyloric antrum resulting in gastric outlet obstruction by gallstones is indeed rare. In the past, the majority of surgeons reporting on gallstone ileus were of the opinion that no attempt should be made to resect the cholecystoenteric fistula during the initial procedure to relieve acute obstruction. More recently though, after reviewing the large morbidity which attends enterotomy alone, more and more surgeons are advocating aggressive primary approach to the management of gallstone ileus. This paper reports a case of cholecystopyloric fistula with gallstones impacted in the pylorus, gastric antrum and duodenum resulting in gastric outlet obstruction and treated by primary cholecystectomy, closure of the pyloric fistula, Jaboulay gastroduodenostomy and vagotomy.

Because biliary intestinal fistulas have no specific ~yrnptoms or physical signs, they are often overlooked mtil related complications occur. These complications it~clude gallstone iteus, obstruction of the common bile duct, cholangitis, hemorrhage from the fistula, :,nd obstruction of the small intestine or colon as a ~csult of extrinsic inflammation. The management of i~atients with biliary intestinal fistulas is therefore ~sually complex and often controversial. Whether or ,aot the fistula should be repaired during operations for gallstone ileus and what procedure to perform in cases in which a fistula is the result of peptic ulcer :~re examples of the problems in management. This p~per is a review and discussion of the etiology, associated complications, and management of twentytwo patients with biliary intestinal fistulas. Clinical Material

Thirty-nine cases of recurrent intestinal obstruction from gallstones emphasize the necessity and means of discovering other calculi within the gastrointestinal system by thorough exploration at the time of the original surgery and by roentgenographic examination later. If further surgery is indicated, cholecystostomy may be both palliative and curative.

IN 1922 Pybus successfully extracted an obstructing gallstone from the ileum, closed the duodenal fistula, and drained the gallbladder after removing two additional stones from it. This was done because of the author's previous disastrous experience with recurrent gallstone ileus. 1 Seven years later Holz removed a faceted stone from the sigmoid and was obliged to close the cholecyst-duodenal fistula while removing a second stone that was impacted in the duodenum. In addition he elected to remove the gallbladder. The patient survived and Holz commented that with similar findings such a procedure can be recommended if the patient's general condition is satisfactory. 2 Welch et al (1957) in dealing with a recurrent gallstone intestinal obstruction performed a successful one-stage resection in a patient who was well prepared for three days preoperatively. Again the authors suggested the feasibility of the operation under optimal conditions. 17 We are not aware of any

Forty cases of gallstone ileus are summarized in terms of incidence, physical findings and operative therapy. Vomiting with crampy abdominal pain was the chief complaint in the majority, and over half of the patients had a past history of cholecystitis or jaundice. Accuracy of preoperative diagnosis is increased if the physician has a high index of suspicion in the case of elderly patients with small-bowel obstruction of obscure etiology. Gastrografin or barium upper-gastrointestinal x-ray examinations help to outline a cholecystoduodenal fistula or obstructive stone, especially in patients with a high small-bowel obstruction. Discussion centers on three forms of surgical therapy: 1) enterotomy, 2) enterotomy with interval cholecystectomy and closure of the biliary-enteric fistula, and 3) total one-stage repair as an initial procedure. The data and observations confirm the opinion that enterotomy followed by an interval cholecystectomy, or selective total one-stage repair of the cholecystoduodenal fistula with enterotomy, are the treatments of choice in patients with gallstone ileus.

GALLSTONE ileus as a complication of cholecystoduodenal fistula, and its surgical management, has been well emphasized in the literature. Massive upper-gastrointestinal tract hemorrhage as a result of a cholecystoenteric fistula is a rare entity.1,2Erosion of the cystic artery from a gallstone perforation of the duodenum presenting as hematemesis has not been previously reported. The following case reports illustrate this unusual occurrence. Report of Cases Case1 (MGH-32961).—An 81-year-old woman was admitted to the Massachusetts General Hospital in June 1967 with a one-week history of epigastric pain and hematemesis on the day of admission. She had been in good general health except for mild symptoms of congestive heart-failure diagnosed on the basis of the presence of arteriosclerotic heart disease. There was no past history of abdominal pain, fatty-food intolerance, or jaundice. On admission, the patient's blood pressure and pulse were normal. She had no jaundice. There was

Obstruction of the small bowel resulting from an acute inflammation of the gallbladder is rare. Blain and Harkins 1 studied reports of 11,794 operations and 19,274 necropsies and found 41 cases of perforated gallbladder. In 11 cases there was associated intestinal obstruction; however, only 4 cases presented as obstruction, and in 2 of those the obstruction was a gallstone ileus. Their series did not include the intact, nonperforated, acutely inflamed gallbladder. Nemir, 2 in his study of 430 cases treated during a 10-year period at the Hospital of the University of Pennsylvania, describes no case similar to the one we are reporting. Furthermore, in a search of the indexed literature for the past 17 years no published case report was found. Analysis of the Cleveland Clinic records indicates that the case to be reported is the first such case seen here, in which the only complaints and findings are related

THE combination of gallstone ileus, volvulus of the small intestine, incarcerated femoral hernia and diffuse peritonitis is sufficiently unusual to warrant a report. The probable sequence of events...

A 64-year-old man with fecal vomiting is the 20th patient recorded with a cholecysto-duodeno-colic fistula and the second to have a concomitant gallstone ileus. All 20 cases have been due to complicated cholelithiasis. A survey reveals the cardinal features to be that of vomiting (often feculent), air in the biliary tree on roentgenograms, and the invariable demonstration by barium enema of a colonic fistula.

The surgical complications of biliary-tract disease are discussed in relation to a study comprising 18 cases of cholecystoduodenal fistula, 6 cases of gallstone ileus, and representative cases of gallstones, pancreatitis and suppurative cholangitis. The average age of the patients was 67 years. The findings led to the following conclusions: 1) age is an important factor in the increased risk in these complicated cases, but with careful management, surgery can be successful; 2) acute cholecystitis usually can be treated conservatively in aged patients, but all too often the patients ignore the recommendation for an elective operation and are later admitted to the hospital with complications that demand emergency surgery; 3) this sequence of events applies particularly to patients with biliary calculi, who should undergo an elective operation before more serious complications develop. Had our patients been operated on earlier, the surgical risk would have been minimal and the complications would have been prevented.

Gallstone ileus can be defined as mechanical intestinal obstruction due to intraluminal occlusion of bowel by a biliary calculus. 1 Although it was once thought to be a unique clinical entity, it is not so uncommon that the average surgeon has not observed at least one case. Bartholin was the first to record a case of cholecystoenteric fistula with entrance of a gallstone into the intestinal tract, in a patient examined at autopsy in 1654. 2 Courvoisier published the first article in 1890 in which he reported on 131 cases of gallstone ileus. 3 It is interesting to note that the mortality in the 125 operations which were performed for this condition was 44%. Since that time comprehensive reviews of the literature and recorded additional cases, 4-7 have augmented our understanding of this entity, as well as its proper management. It is the purpose of this report to review the

Acute complete mechanical large bowel obstruction presents a dramatic clinical picture and requires early definitive therapy, usually surgical, if the closed loop type of obstruction produced is to be relieved before the complications of proximal perforation or local strangulation (as in volvulus) develop, or the deleterious cardiorespiratory effects of extreme abdominal distention occur. The usual causes of large bowel obstruction are carcinoma, volvulus of the sigmoid colon, or cecum, incarcerated hernia, and diverticulitis, which make up at least 90% of all series of case reports. Rarely, strictures related to trauma or irradiation, inflammatory diseases, extrinsic masses, foreign bodies, and adhesions may cause obstruction. A recent case in surgical practice has illustrated an unusual type of acute colonic obstruction and seems worthy of presentation because of its rarity. Report of a Case The case to be reported is that of an 87-year-old white man who was first seen by me on

One of the more uncommon causes of acute intestinal obstruction is impaction of a gallstone in the intestinal lumen. Almost without exception, this is the result of a spontaneous internal biliary fistula, occurring most frequently between the gallbladder and the duodenum. A gallstone ileus, in the absence of a previous communication between intestine and biliary tree, is, however, a rare occurrence; only two such cases have been discovered in the literature. The site of formation of the stone in one of these cases was a duodenal diverticulum 1 and in the other a blind duodenal stump following subtotal gastrectomy. 2 It is the purpose of this report to review briefly the problem of gallstone obstruction of the intestinal tract and to present a third case of acute intestinal obstruction resulting from impaction of a large gallstone in the terminal ileum in the absence of a previous biliary-tract fistula. Incidence In

To the Editor. —We are writing to describe a case in which gallstone obstruction of the distal part of the ileum was diagnosed preoperatively by barium contrast examination of the colon. Report of a Case A 75-year-old white man had a four-day history of intermittent symptoms suggestive of the "tumbling" or "migrating" phenomenon of intermittent obstruction occurring at more caudal areas in the small intestine, as a result of a stone being pushed distally by peristaltic action. The admission roentgenographic diagnosis was small intestinal obstruction. Barium enema examination was performed (Figure), and the barium column refluxed past the ileocecal valve into the terminal part of the ileum, and around an obstructing intraluminal mass (gallstone). Although the intraluminal mass may have represented a tumor, the clinical course suggested a gallstone. At surgery, an obstructing, 3 × 2.3 × 2.0-cm, intraluminal stone was identified and removed. Comment There is frequent difficulty in

To the Editor.— Gallstone ileus is a rare but well-defined entity that usually can be recognized easily at surgery. We report a case that closely resembled gallstone ileus but which was caused by a "pseudogallstone." Report of a Case.— A 55-year-old Tunisian farmer entered the hospital because of vomiting and abdominal pain. For several months he had noted vague diffuse abdominal pain. During the week before admission the pain became cramp-like and intense; there was bilious vomiting and obstipation. On examination the temperature was normal but he was hypotensive and oliguric. The abdomen was distended, tense, and tender throughout. The white blood cell count was 12,500/cu mm, red blood cell count was 3,900,000/ cu mm, and hemoglobin value was 42%. A plain film of the abdomen revealed an ovoid calculus in the pelvis. Small bowel distension was present. About three hours after admission the patient underwent laparotomy. Generalized peritonitis was

TABLE OF CONTENTS Introduction Esophagus Motility Esophageal Pain Atresia Esophagitis Ulcer Mediastinitis Scleroderma Varices Cardiospasm Carcinoma Stomach Anorexia Nervosa Pernicious Vomiting of Pregnancy Diaphragmatic Hernia Gastric Motility Gastric Secretion Gastroscopy Gastritis Hypertrophic Pyloric Stenosis Foreign Bodies Syphilis Actinomycosis Fibrosis Surgery for Functional Disturbances Peptic Ulcer Historical Incidence Etiology Trauma Roentgenology Treatment Alkalosis Surgical Treatment Massive Hemorrhage Jejunal Ulcer Acute Perforation Ulcer in Childhood Ulcer and Military Service Gastric Cancer Incidence Experimental Production Gastritis and Cancer Prognosis and Classification Natural History Diagnosis Surgical Treatment Benign Tumors Lymphosarcoma Hodgkin's Disease Duodenum Diverticula Obstruction Cyst Rupture Cancer Sarcoma Small Intestine Physiology Roentgenology Anomalies Volvulus Intussusception Stenosis and Adhesions Bezoar Rupture Aneurysm Gallstone Ileus Diverticula Treatment of Intestinal Obstruction Sprue and Related Disorders Regional Enteritis Cyst Benign Tumors Carcinoid Tumors Carcinoma Sarcoma Appendix Acute Appendicitis Etiology Diagnosis Treatment Dysentery and Diarrheal Diseases Epidemic Diarrhea of the Newborn Vitamin Deficiency Food Poisoning Bacillary Dysentery Chemotherapy

Preoperative roentgen diagnosis of intestinal obstruction due to gallstone has only rarely been recorded in the literature. In a series of 3,064 cases of intestinal obstruction reported by the British Medical Association 1 the incidence of gallstone as the causative factor was twenty-eight cases, or 0.9 per cent. In none of these cases was a diagnosis reported as having been made preoperatively. Wilms 2 reviewed the availablestatistics in Germany and found gallstones as the cause of obstruction in 2.1 per cent of cases. Sante 3 found four cases in 287 of obstruction of the bowel. The operative mortality varies between 40 and 50 per cent, and most surgeons believe that delay in operating is largely responsible for the high death rate. A review of the literature reveals only seven cases 4 in which a definite diagnosis of gallstone ileus was established prior to operation; these are listed in the

An unequivocal preoperative diagnosis of small-intestinal ileus is very often difficult to make, and a positive determination of the etiology of such obstruction is usually impossible. Once a fairly certain diagnosis has been established, it becomes extremely important to discover the source of the trouble without unnecessary delay, for the correct management of the condition may depend upon the identification of the causative agent. Certain mechanical small-bowel obstructions can be treated conservatively, deliberately, and nonsurgically, with complete symptomatic relief, by decompression suction therapy. In most cases of small-intestinal ileus, however, dilatory procedures are contraindicated and procrastination is hazardous. The delay is particularly dangerous when such ileus is caused by an impacted gallstone, for the mortality rate in cholelithic obstruction has been reported as varying from 30% to 70%, owing, in great part, to the tardiness in diagnosis and treatment.5Since it is an accepted fact that radiologic examination of

Gallstone ileus is a mechanical intestinal obstruction caused by impaction of one or more gallstones within the bowel lumen. It is a continuing surgical problem and occurs mainly in the elderly. Preoperative diagnosis depends upon x-ray film findings of distended loops of bowel, air in the biliary tract, and a stone in the intestine. The prime objective of gallstone ileus treatment is surgical relief of the obstruction. However, under optimum conditions, a one-stage repair of the associated biliary tract disease should be done. The syndrome is reviewed and four new cases illustrative of the various means of treatment are presented.

The presence of air or barium in the biliary tract indicates either an internal biliary fistula or regurgitation through an incompetent sphincter of Oddi. The finding of air in the biliary tract assumes special significance in the presence of small-bowel obstruction. In such a case the diagnosis of gallstone ileus is very strongly suggested, even though no calculus is visible. Within the past year we have seen six patients who had either air or barium in the biliary tract. One patient had a cholecytocolic fistula, one had a cholecystoduodenal fistula; in one patient there was regurgitation through an incompetent sphincter of Oddi secondary to a chronic pancreatitis, in two cases the cause was not determined anatomically, and in one patient a cholecystojejunostomy had been performed one year previously for carcinoma of the ampulla of Vater. Incidence, Etiology, and Significance Spontaneous internal biliary fistulas are among the least common complications of

The recognition of the specific nature of an obstructing lesion of the bowel is a vastly important expedient in the proper management of intestinal obstruction. With the introduction of suction therapy for the treatment of acute obstruction by Wangensteen and Paine, 1 the need for exact diagnosis has become even more pressing. While it is clear that in certain cases simple mechanical obstruction of the small bowel can be treated successfully without recourse to surgery, the management of obstruction of the small bowel by decompression is not without danger, especially when the exact nature of the lesion has not been ascertained. In certain instances of diagnostic uncertainty, suction decompression of the bowel postpones the inevitable train of events and creates a false sense of security. Gallstone ileus is one of the conditions in which temporizing procedures are not indicated; once this diagnosis is established, the hazard of any procedure other

Internal biliary fistulas may arise from peptic ulceration, operative trauma or, most commonly, as a result of biliary disease with associated calculi. Of the latter group the most frequently seen is the communication between the gallbladder and the upper small bowel through ulceration of a gallstone into the duodenum; this may result in gallstone ileus. Less commonly fistulas develop between the common bile duct and the duodenum from stones in the duct eroding into the bowel or from the penetration of a peptic ulcer into the common duct. Uncommon too are the fistulas between the biliary tract and the colon. In 1925 Judd and Burden4reported 26 cholecystocolic fistulas as part of a series of 153 cases of internal biliary fistula seen at the Mayo Clinic. In one of the 26 the diagnosis had been made preoperatively by barium enema. Bernhard1reported 36 of 109 internal biliary fistulas