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1.  Gallstone ileus: Case report and literature review 
Gallstone ileus (GI) is characterized by occlusion of the intestinal lumen as a result of one or more gallstones. GI is a rare complication of gallstones that occurs in 1%-4% of all cases of bowel obstruction. The mortality associated with GI ranges between 12% and 27%. Classical findings on plain abdominal radiography include: (1) pneumobilia; (2) intestinal obstruction; (3) an aberrantly located gallstone; and (4) change of location of a previously observed stone. The optimal management of acute GI is controversial and can be: (1) enterotomy with stone extraction alone; (2) enterotomy, stone extraction, cholecystectomy and fistula closure; (3) bowel resection alone; and (4) bowel resection with fistula closure. We describe a case to highlight some of the pertinent issues involved in GI management, and propose a scheme to minimize recurrent disease and postoperative complications. We conclude that GI is a rare condition affecting mainly the older population with a female predominance. The advent of computed tomography and magnetic resonance imaging has made it easier to diagnose GI. Enterotomy with stone extraction alone remains the most common surgical method because of its low incidence of complications.
doi:10.3748/wjg.v19.i33.5586
PMCID: PMC3761115  PMID: 24023505
Gallstone ileus; Fistula closure; Intestinal obstruction; Bowel obstruction; Enterolithotomy
2.  Pneumobilia: A Case Report and Literature Review on its Surgical Approaches 
Gallstones ileus is an uncommon cause but important cause of small bowel obstruction. The gallstone enters the intestinal lumen via a fistula located in the duodenum (cholecystoduodenal), or rarely, in the colon (cholecystocolonic) or stomach (cholecystogastric). This may result in large bowel or gastric outlet obstruction (Bouveret's Syndrome). Gallstone ileus affects the elderly females pre-dominantly and is associated with a high morbidity and mortality rate if diagnosis and urgent surgical intervention are delayed. In this paper, we report on the case of an elderly lady who presented with classical symptoms and signs of small bowel obstruction. She was subsequently diagnosed with gallstone ileus due to a large gallstones lodged in the intestinal lumen. We perform a literature review on this rare disease and discuss the two main surgical approaches in managing this condition. Gallstone ileus should be considered in the differential diagnosis of small bowel obstruction especially in elderly women who have no history of abdominal surgery or abdominal hernia. Early intervention is important because of the high mortality rate due to the poor general condition that often exists in this subgroup of patients. There is no general consensus on gold standard surgical approach in these cases but a two-stage procedure (either enterotomy alone or enterotomy and subsequent cholecystectomy) has been shown to be associated with lower mortality rates.
doi:10.4103/2006-8808.118616
PMCID: PMC3889000  PMID: 24470847
Gallstone ileus; pneumobilia; rigler's triad; small bowel obstruction
3.  Development of a duodenal gallstone ileus with gastric outlet obstruction (Bouveret syndrome) four months after successful treatment of symptomatic gallstone disease with cholecystitis and cholangitis: a case report 
Introduction
Cases of gallstone ileus account for 1% to 4% of all instances of mechanical bowel obstruction. The majority of obstructing gallstones are located in the terminal ileum. Less than 10% of impacted gallstones are located in the duodenum. A gastric outlet obstruction secondary to a gallstone ileus is known as Bouveret syndrome. Gallstones usually enter the bowel through a biliary enteral fistula. Little is known about the formation of such fistulae in the course of gallstone disease.
Case presentation
We report the case of a 72-year-old Caucasian woman born in Germany with a gastric outlet obstruction due to a gallstone ileus (Bouveret syndrome), with a large gallstone impacted in the third part of the duodenum. Diagnostic investigations of our patient included plain abdominal films, gastroscopy and abdominal computed tomography, which showed a biliary enteric fistula between the gallbladder and the duodenal bulb. Our patient was successfully treated by laparotomy, duodenotomy, extraction of the stone, cholecystectomy, and resection of the fistula in a one-stage surgical approach. Histopathological examination showed chronic and acute cholecystitis, with perforated ulceration of the duodenal wall and acute purulent inflammation of the surrounding fatty tissue. Four months prior to developing a gallstone ileus our patient had been hospitalized for cholecystitis, a large gallstone in the gallbladder, cholangitis and a small obstructing gallstone in the common biliary duct. She had been treated with endoscopic retrograde cholangiopancreatography, endoscopic biliary sphincterotomy, balloon extraction of the common biliary duct gallstone, and intravenous antibiotics. At the time of her first presentation, abdominal ultrasound and endoscopic examination (including esophagogastroduodenoscopy and endoscopic retrograde cholangiopancreatography) had not shown any evidence of a biliary enteral fistula. In the four months preceding the gallstone ileus our patient had been asymptomatic.
Conclusion
In patients known to have gallstone disease presenting with symptoms of ileus, the differential diagnosis of a gallstone ileus should be considered even in the absence of preceding symptoms related to the gallbladder disease. Gallstones large enough to cause intestinal obstruction usually enter the bowel by a biliary enteral fistula. During the formation of such a fistula, patients can be asymptomatic.
doi:10.1186/1752-1947-4-376
PMCID: PMC2997099  PMID: 21092262
4.  Laparoscopic Management of Gallstone Ileus 
Gallstone ileus is an uncommon entity that was first described by Bartholin in 1654. Despite advances in peri-operative care, morbidity and mortality remain high in patients with gallstone ileus because: 1) they are geriatric patients; 2) they often have multiple comorbidities; 3) presentation to the hospital is delayed; 4) many are volume depleted with electrolyte abnormalities; and 5) the diagnosis of gallstone ileus is difficult to make. Traditional management has entailed open laparotomy with relief of intestinal obstruction by enterotomy and stone extraction. Cholecystectomy and takedown of the cholecystoenteric fistula can be performed.
We propose an alternative method of management in an attempt to limit operative trauma and improve morbidity and mortality. We review the literature and describe two patients with gallstone ileus who were managed laparoscopically. One patient underwent laparoscopic assisted enterolithotomy, and the other patient underwent diagnostic laparoscopy with disimpaction of the gallstone into the large bowel. They were discharged after their ileus had resolved on the fourth and sixth postoperative day, respectively.
Laparoscopy is a powerful diagnostic and therapeutic tool that can be effectively used to treat gallstone ileus.
PMCID: PMC3015453  PMID: 11548836
Gallstone ileus; Laparoscopy; Bowel obstruction; Cholecystoenteric fistula
5.  Spontaneous resolution of a gallstone ileus 
Gallstone ileus is an uncommon complication of cholelithiasis, usually associated with an internal biliary fistula. Management of gallstone ileus is surgical with enterolithotomy the procedure of choice, followed by fistula closure either as a one or two stage procedure. In this case a 66 year old female presented with colicky abdominal pain, computed tomography (CT) clearly showing a gallstone ileus and cholecystoduodenal fistula. Despite this the patient refused surgery and went on to have spontaneous resolution of the obstruction and passage of gallstones.
doi:10.1093/jscr/2012.3.3
PMCID: PMC3649501
6.  A case of gallstone ileus displaying spontaneous closure of cholecystoduodenal fistula after enterolithotomy 
INTRODUCTION
Gallstone ileus, a rare complication of cholelithiasis and cholecystitis, is a relatively rare cause of alimentary tract obstruction. It is usually associated with a cholecystoenteric fistula through which a gallstone has passed into the gastrointestinal tract. Cholecystoenteric fistula uncommonly closes spontaneously, the period between formation and closure having rarely been reported. In addition, endoscopic detection of cholecystoenteric fistulous closure has seldom been reported.
PRESENTATION OF CASE
We report a 51-year-old Japanese man with gallstone ileus in whom spontaneous closure of a cholecystoduodenal fistula was observed by endoscopy 2 weeks after laparoscopy-assisted enterolithotomy.
DISCUSSION
Laparoscopy-assisted enterolithotomy for gallstone ileus allows direct diagnosis of gallstone ileus and assessment of the status of adhesions affecting the biliary tract.
CONCLUSION
Endoscopic confirmation of fistulous closure after laparoscopy-assisted enterolithotomy is a minimally invasive approach that may avert the need for biliary surgery.
doi:10.1016/j.ijscr.2011.07.012
PMCID: PMC3267243  PMID: 22288031
Cholecystoduodenal fistula; Endoscopy; Gallstone; Ileus; Enterolithotomy
7.  Laparoscopic Enterolithotomy Is a Valid Option to Treat Gallstone Ileus 
This report describes a case of gallstone ileus managed with a totally laparoscopic approach.
Gallstone ileus is a well-recognized clinical entity. It usually affects elderly female patients, and very often diagnosis can be delayed resulting in high morbidity and mortality. An abdominal x-ray and computed tomographic (CT) scan of the abdomen may show classical radiological features of small bowel obstruction, pneumobilia, and an ectopic gallstone. Laparotomy and enterlithotomy with or without definite biliary surgery is an established treatment. Since 1992, many cases of laparoscopic-assisted enterolithotomy have been reported. Only a few cases of a totally laparoscopic approach have been documented. We present the case of a 75-year-old lady who presented with features of intestinal obstruction. A plain x-ray of the abdomen and a CT scan confirmed the classical features of gallstone ileus. A totally laparoscopic enterolithotomy was performed using 6 ports. A 6-cm gallstone was retrieved through a longitudinal enterotomy. The transverse closure of the enterotomy was performed with intracorporeal suturing, resulting in an uneventful postoperative recovery. We suggest that a CT scan helps in the early diagnosis of the cause of intestinal obstruction, and totally laparoscopic enterolithomy with intracorporeal enterotomy repair is a valid, safe option.
doi:10.4293/108680810X12785289144764
PMCID: PMC3043585  PMID: 20932386
Gallstone ileus; Laparoscopic enterolithotomy; Small bowel obstruction; Laparoscopy
8.  Gastric outlet obstruction in a patient with Bouveret’s syndrome: a case report 
BMC Research Notes  2013;6:195.
Background
Gallstone ileus accounts for 1% to 4% of cases of mechanical bowel obstruction, but may be responsible for up to 25% of cases in older age groups. In non-iatrogenic cases, gallstone migration occurs after formation of a biliary-enteric fistula. In fewer than 10% of patients with gallstone ileus, the impacted gallstones are located in the pylorus or duodenum, resulting in gastric outlet obstruction, known as Bouveret’s syndrome.
Case presentation
We report an 86-year-old female who was admitted to hospital with a 10-day history of persistent vomiting and prostration. She was in hypovolemic shock at the time of arrival in the emergency department. Investigations revealed a gallstone in the duodenal bulb and a cholecystoduodenal fistula. She underwent surgical gastrolithotomy. Unfortunately, she died of aspiration pneumonia on the fourth postoperative day.
Conclusion
This case shows the importance of considering Bouveret’s syndrome in the differential diagnosis of gastric outlet obstruction, especially in the elderly, even in patients with no previous history of gallbladder disease.
doi:10.1186/1756-0500-6-195
PMCID: PMC3660164  PMID: 23663702
Bouveret’s syndrome; Gallstone ileus; Gastric outlet obstruction; Cholecystoduodenal fistula
9.  The operative management of gallstone ileus 
INTRODUCTION
Gallstone ileus is an uncommon entity, which accounts for 1–4% of all presentations to hospital with small bowel obstruction and for up to 25% of all cases in patients over 65 years of age. Despite medical advances over the last 350 years, gallstone ileus is still associated with high rates of morbidity and mortality. The management of gallstone ileus remains controversial. Whilst open surgery has been the mainstay of treatment, more recently other approaches have been employed, including laparoscopic surgery and lithotripsy. However, controversy persists primarily in relation to the extent of surgery performed.
MATERIALS AND METHODS
A literature review was performed in an attempt to discover the optimal surgical treatment of gallstone ileus, particularly the timing of biliary surgery. Published articles were identified from the medical literature by electronic searches of Pubmed and Ovid Medline databases, using the search terms ‘gallstone ileus’, ‘gallstone/intestinal obstruction’ and ‘gallstone/bowel obstruction’. The related articles function of the search engines was also used to maximise the number of articles identified. Relevant articles were retrieved and additional articles were identified from the references cited in these articles.
RESULTS AND CONCLUSIONS
The literature on gallstone ileus is composed entirely of retrospective analysis of small numbers of patients accumulated over many years. The question as to whether one stage or interval biliary surgery should be performed remains unanswered and it is unlikely that further case series will help decision making in the management of gallstone ileus. Whilst many authors conclude that enterolithotomy alone is the best option in most patients, a one-stage procedure should be considered for low-risk patients.
doi:10.1308/003588410X12664192076377
PMCID: PMC3025194  PMID: 20501012
Gallstone ileus; Intestinal obstruction; Bowel obstruction; Enterolithotomy
10.  Surgical Relief of Small Bowel Obstruction by Migrated Biliary Stent: Extraction Without Enterotomy 
Small bowel obstruction caused by biliary stent migration may be managed without enterotomy by using a combination of laparoscopy, endoscopy, and fluoroscopy.
Background:
Distal stent migration is a well-known complication following insertion of biliary stents. Most such cases can be managed expectantly, because the stents pass through the gastrointestinal tract. However, small bowel obstruction as a result of the stent mandates surgical intervention.
Methods:
We report the case of a patient who had distal stent migration causing a small bowel obstruction. We successfully retrieved the stent without an enterotomy, by using a combination of laparoscopy, endoscopy, and fluoroscopy. Our unique technique greatly decreased the risk of bacterial peritonitis in this patient with decompensated cirrhosis and associated ascites, which in this patient population results in a high mortality.
Results:
Management of small bowel obstruction secondary to biliary stent migration necessitates operative intervention. Retrieval of a dislodged stent can be performed safely without subjecting the patient to an enterotomy or a small bowel resection. Postoperative morbidity should be significantly reduced by this approach.
Conclusion:
Retrieval of biliary stents in cases of small bowel obstruction without perforation may be successfully performed without enterotomy or bowel resection. A similar approach may be applied to other foreign bodies dislodged in the small bowel.
doi:10.4293/108680811X13071180406998
PMCID: PMC3148878  PMID: 21902982
Biliary stent migration; Surgical management of small bowel obstruction from biliary stent migration
11.  A challenging case of gastric outlet obstruction (Bouveret's syndrome): a case report 
Introduction
Bouveret's syndrome is a clinically distinct form of gallstone ileus caused by the formation of a fistula between the biliary tract and duodenum. This case reinforces the need for early recognition and treatment of Bouveret's syndrome, as it is associated with high morbidity and mortality rates.
Case presentation
An 82-year-old Caucasian woman presented with signs and symptoms of small bowel obstruction. Her laboratory workup showed elevated alkaline phosphatase and amylase levels. Computed tomography of her abdomen revealed pneumobilia, a choledochoduodenal fistula and a gallstone obstructing her distal duodenum. The impacted gallstone could not be extracted endoscopically, so our patient underwent open enterolithotomy successfully. However, the postoperative course was complicated by myocardial infarction, respiratory failure and disseminated intravascular coagulation. She died 22 days after surgery, secondary to cardiopulmonary arrest.
Conclusion
This case clearly highlights the considerable morbidity and mortality associated with Bouveret's syndrome.
doi:10.1186/1752-1947-5-497
PMCID: PMC3204302  PMID: 21970809
12.  Large bowel and small bowel obstruction due to gallstones in the same patient 
BMJ Case Reports  2011;2011:bcr0920103372.
This is the case report of an 85-year-old woman who on two consecutive occasions presented with acute abdominal pain. The first presentation was large bowel obstruction. CT abdomen revealed this was due to a cholecystocolic fistula, allowing a large gallstone to pass and obstruct in the sigmoid colon. The second presentation was after laparotomy; the second CT abdomen revealed another gallstone causing small bowel obstruction. This case is interesting because cholelithiasis rarely leads to sigmoid colon obstruction (gallstone coleus)1 and gallstone ileus. Unfortunately, this patient had both. A gallstone causing obstruction in either the small or large bowel is rare, but occurrence of both in the same patient has not been reported to date. This case also shows how the elderly unwell surgical patient was mismanaged and she could have been spared surgery and irradiation if she was managed appropriately from the start.
doi:10.1136/bcr.09.2010.3372
PMCID: PMC3083017  PMID: 22696674
13.  Gallstone ileus following endoscopic retrograde cholangiopancreatography and sphincterotomy: a case report 
Introduction
Gallstone ileus is a mechanical obstruction caused by the impaction of one or more gallstones within the lumen of any part of the gastrointestinal tract. Although the disorder is a rare cause of small bowel obstruction (1% to 2%), it has been reported to cause up to 25% of cases of non-strangulated small bowel obstruction in patients over 65 years of age.
Case presentation
We report a case of a 67-year-old woman who presented with gallstone ileus following endoscopic retrograde cholangiopancreatography and sphincterotomy for choledocholithiasis. She had a history of terminal ileum resection with ileocolic anastomosis for Crohn's disease. A 3 cm gallstone was found to be impacted just proximal to the previous ileocolic anastomosis. A second gallstone was found on digital examination of the proximal small bowel.
Conclusion
A gallstone may enter the gastrointestinal tract following endoscopic retrograde cholangiopancreatography and sphincterotomy and impact proximal to an anastomotic stricture as demonstrated here. The radiographic image of small bowel obstruction plus air in the biliary tree is a classic diagnostic finding. After stone extraction, the entire small bowel and colon should be digitally examined for further stones.
doi:10.1186/1752-1947-2-342
PMCID: PMC2584010  PMID: 18990216
14.  Complicated Cholelithiasis: An Unusual Combination of Acute Pancreatitis and Bouveret Syndrome 
Case Reports in Gastroenterology  2012;6(2):459-464.
Bouveret syndrome is a rare form of gallstone ileus. The purpose of the present study was to present the unusual case of a female patient with complicated cholelithiasis manifested as a combination of acute pancreatitis and concomitant Bouveret syndrome. A 61-year-old female patient was admitted to the emergency department complaining of mid-epigastric and right upper quadrant abdominal pain radiating band-like in the thoracic region of the back as well as repeated episodes of vomiting over the last 24 h. The initial correct diagnosis of pancreatitis was subsequently combined with the diagnosis of Bouveret syndrome as a computed tomography scan revealed the presence of a gallstone within the duodenum causing luminal obstruction. After failure of endoscopic gallstone removal, a surgical approach was undertaken where gallstone removal was followed by cholecystectomy and restoration of the anatomy by eliminating the fistula. The concomitant pancreatitis complicated the postoperative period and prolonged the length of hospital stay. However, the patient was discharge on the 45th postoperative day. Attempts for endoscopic removal of the impacted stone should be the initial therapeutic step. Surgery should be reserved for cases refractory to endoscopic intervention and when definite treatment is the actual challenge.
doi:10.1159/000341512
PMCID: PMC3398075  PMID: 22855661
Complicated cholelithiasis; Acute pancreatitis; Bouveret syndrome; Duodenal obstruction; Gallstone ileus
15.  Usefulness of CT-scan in the diagnosis and therapeutic approach of gallstone ileus: report of two surgically treated cases 
BMC Surgery  2013;13(Suppl 2):S6.
Background
Gallstone ileus is a rare cause of gastrointestinal obstruction, more frequent in elderly patients, whose treatment is essentially surgical, although some para-surgical and mini-invasive possibilities exist, allowing the solution of such obstructive condition in a completely non-invasive way.
Description
In our study, after reporting two cases of biliary ileus managed by our surgical division, we will analyze the most suitable diagnostic procedures and the therapeutic approaches to this pathology.
Conclusions
Gallstone ileus is a quite rare pathology in population, but affects more frequently elderly people; The treatment of this disease is mainly surgical.
doi:10.1186/1471-2482-13-S2-S6
PMCID: PMC3850963  PMID: 24268073
16.  Jejunal perforation in gallstone ileus – a case series 
Introduction
Gallstone ileus is an uncommon complication of cholelithiasis but an established cause of mechanical bowel obstruction in the elderly. Perforation of the small intestine proximal to the obstructing gallstone is rare, and only a handful of cases have been reported. We present two cases of perforation of the jejunum in gallstone ileus, and remarkably in one case, the gallstone ileus caused perforation of a jejunal diverticulum and is to the best of our knowledge the first such case to be described.
Case presentations
Case 1
A 69 year old man presented with two days of vomiting and central abdominal pain. He underwent laparotomy for small bowel obstruction and was found to have a gallstone obstructing the mid-ileum. There was a 2 mm perforation in the anti-mesenteric border of the dilated proximal jejunum. The gallstone was removed and the perforated segment of jejunum was resected.
Case 2
A 68 year old man presented with a four day history of vomiting and central abdominal pain. Chest and abdominal radiography were unremarkable however a subsequent CT scan of the abdomen showed aerobilia. At laparotomy his distal ileum was found to be obstructed by an impacted gallstone and there was a perforated diverticulum on the mesenteric surface of the mid-jejunum. An enterolithotomy and resection of the perforated small bowel was performed.
Conclusion
Gallstone ileus remains a diagnostic challenge despite advances in imaging techniques, and pre-operative diagnosis is often delayed. Partly due to the elderly population it affects, gallstone ileus continues to have both high morbidity and mortality rates. On reviewing the literature, the most appropriate surgical intervention remains unclear.
Jejunal perforation in gallstone ileus is extremely rare. The cases described illustrate two quite different causes of perforation complicating gallstone ileus. In the first case, perforation was probably due to pressure necrosis caused by the gallstone. The second case was complicated by the presence of a perforated jejunal diverticulum, which was likely to have been secondary to the increased intra-luminal pressure proximal to the obstructing gallstone.
These cases should raise awareness of the complications associated with both gallstone ileus, and small bowel diverticula.
doi:10.1186/1752-1947-1-157
PMCID: PMC2222670  PMID: 18045463
17.  Successful Endoscopic Management of Bouveret's Syndrome in a Patient with Cholecystoduodenocolic Fistulae 
Case Reports in Gastroenterology  2008;2(3):346-350.
Bouveret's syndrome, first described in 1896 by Léon Bouveret, is rare, limited to approximately 200 published case reports to date [Ariche et al.: Scand J Gastroenterol 2000;35:781–783]. It is a subgroup of gallstone ileus in which a cholecystoduodenal fistula allows the passage of a gallstone that obstructs the duodenum, causing gastric outlet obstruction. This case is unique as it describes Bouveret's syndrome in a patient with combined cholecystoduodenocolic fistulae. Gastric outlet obstruction was successfully managed endoscopically with lithotripsy. Both fistulae were subsequently managed conservatively without any complications.
doi:10.1159/000151581
PMCID: PMC3075195  PMID: 21490867
Bouveret; Gallstone; Cholecystoduodenal; Cholecystocolic
18.  Cholecystostomy does not prevent gallstone ileus: a case report 
Cases Journal  2009;2:6790.
Introduction
Gallstone ileus following cholecystostomy has been reported once, in a patient with acute cholecystitis, where symptoms of small intestinal obstruction had developed one day after surgery. We report a case of gallstone ileus eight months following a cholecystostomy, which might deter the diagnosis. This is the only such reported case in medical literature according to our knowledge.
Case presentation
A 54-year-old Sri Lankan female with a past history of a cholecystostomy presented with symptoms suggestive of small intestinal obstruction. Evidence of ileal obstruction with pneumobilia in the supine radiograph of the abdomen and cholecyto-duodenal fistula in the water soluble contrast study was suggestive of the diagnosis of gallstone ileus. An enterolithotomy was performed with no attempt of closure of the cholecysto-duodenal fistula.
Conclusion
This case demonstrates the value of the supine radiograph of the abdomen and the barium follow-through in diagnosis. A cholecystogram, preferably preoperative, is the mainstay of prevention and identification of this clinical scenario.
doi:10.4076/1757-1626-2-6790
PMCID: PMC2740034  PMID: 19829860
19.  Gallstone ileus: One-stage surgery in an elderly patient 
INTRODUCTION
Gallstone ileus (G.I.) is a mechanical bowel obstruction due to impaction of a large gallstone within the bowel and represents an uncommon complication of cholelithiasis. It accounts for 1–4% of all cases of mechanical bowel obstruction, up to 25% in patients over 65 years of age.
PRESENTATION OF CASE
A 75 year old male patient was referred to our hospital in March 2009 with clinical signs of bowel obstruction (abdominal pain and distension, post-prandial vomiting, absolute constipation) during the previous 3 days. A plain abdominal film demonstrated dilated bowel loops, air fluid levels and an image of a stone in the inferior left quadrant. Afterwards, diagnosis of Gallstone ileus was made by means of ultrasonography and colonoscopy. The patient underwent emergent laparotomy and a cholecysto-transverse colon fistula was observed. One-stage procedure consisting of enterolithotomy, cholecystectomy and fistula repair was performed. The post-operative course was complicated by a dehiscence of the colic suture with acute peritonitis. Therefore a colostomy was performed, followed by rapid recovery of general clinical conditions.
DISCUSSION
Surgical treatment for G.I. by cholecysto-enteric fistula is still controversial. Enterolithotomy alone is best suited in all elderly patients with significant comorbidities. One-stage procedure – enterolithotomy, cholecystectomy and fistula repair – should be reserved for young, fit and low risk patients. In our case, mechanical obstruction was associated with a severe cholecystitis with a large fistula between gallbladder and transverse colon.
CONCLUSION
A “radical” surgical option could certainly be characterized by a significant morbidity.
doi:10.1016/j.ijscr.2012.12.016
PMCID: PMC3604665  PMID: 23396396
Gallstone ileus; Elderly patients; Radical surgery
20.  Gallstone ileus--beware the silent second stone. 
Postgraduate Medical Journal  1996;72(847):300-301.
Gallstone ileus remains a rare but important cause of small bowel obstruction. We report a case of recurrent gallstone ileus, presumably caused by an unidentified second stone resident within the gallbladder at the time of the initial laparotomy. This raises important questions about the traditional surgical management of this interesting condition.
Images
PMCID: PMC2398461  PMID: 8761506
21.  A peculiar cause of bowel obstruction 
INTRODUCTION
Gallstone disease is one of the most common surgical problems necessitating intervention. It is estimated that approximately 15% of people in the western world will develop gallstones. Of these patients, 35% of patients initially diagnosed with gallstones will later develop a complication which will eventually result in cholecystectomy.2
One of these complications is gallstone ileus, which is a rare complication associated with high morbidity and mortality, and the diagnosis is often missed.3
PRESENTATION OF CASE
A 66 year old female presented with an acute onset of “colicky” abdominal pain accompanied with vomiting. She had known gallstones diagnosed previously by ultrasound. Her abdomen was generally tender with guarding of the right hypochondrium and absent bowel sounds.
DISCUSSION
Gallstone ileus accounts for 0.5–4% of all cases of small bowel obstruction, and typically affects females over the age of 65.3,4 The pathophysiological basis of the disease involves fistulation of the gallstone through the wall of the gallbladder into the bowel, where it becomes impacted and leads to obstruction. Mortality of the condition is not sufficiently reported, but surgical intervention in itself conveys significant morbidity, and mortality has been reported to be 18%.3,9
CONCLUSION
We report a single large gallstone, which we believe to be one of the largest documented in recent literature, resulting in gallstone ileus. We also present a brief synopsis of the diagnosis and management of the condition, which although rare, should be considered by the astute surgical trainee.
doi:10.1016/j.ijscr.2013.02.003
PMCID: PMC3731718  PMID: 23562895
Acute abdomen; Ileus; Gallstones; Diagnosis and management
22.  A rare cause of upper gastrointestinal haemorrhage: Ruptured cystic artery pseudoaneurysm with concurrent cholecystojejunal fistula☆☆☆ 
INTRODUCTION Cystic artery pseudoaneurysms and cholecystoenteric fistulae represent two rare complications of gallstone disease.
PRESENTATION OF CASE An 86 year old male presented to the emergency department with obstructive jaundice, RUQ pain and subsequent upper gastrointestinal bleeding. Upper GI endoscopy revealed bleeding from the medial wall of the second part of the duodenum and a contrast-enhanced computed tomography scan revealed a cystic artery pseudoaneurysm, concurrent cholecystojejunal fistula and gallstone ileus. This patient was successfully managed surgically with open subtotal cholecystectomy, pseudoaneurysm resection and fistula repair.
DISCUSSION To date there are very few cases describing haemobilia resulting from a bleeding cystic artery pseudoaneurysm. This report is the first to describe upper gastrointestinal bleeding as a consequence of two synchronous rare pathologies: a ruptured cystic artery pseudoaneurysm causing haemobilia and bleeding through a concurrent cholecystojejunal fistula.
CONCLUSION Through this case, we stress the importance of accurate and early diagnosis through ultra- sonography, endoscopy, and contrast-enhanced CT imaging and emphasise that haemobilia should be included in the differential diagnosis of anyone presenting with upper gastrointestinal bleeding. We have demonstrated the success of surgical management alone in the treatment of such a case, but accept that consideration of combined therapeutic approach with angiography be given in the first instance, when available and clinically indicated.
doi:10.1016/j.ijscr.2013.11.005
PMCID: PMC3907196  PMID: 24394852
Cystic Artery; Pseudoaneurysm; Cholecystojejunal fistula; Cholecystoenteric fistula
23.  Large bowel obstruction due to impaction of a gallstone 
BMJ Case Reports  2012;2012:bcr1120115100.
Gallstone ileus is a complication of cholelithiasis resulting from a fistula between the gallbladder and the gastrointestinal tract. If sufficiently large, a gallstone may lodge at the narrowest part of the gastrointestinal tract, usually the terminal ileum, and present with small bowel obstruction. Here the authors present the unusual case of an 82-year-old man who developed symptoms and signs of large bowel obstruction due to an untreated gallstone, measuring 7×4.5 cm, that fistulated into the transvere colon and subsequently impacted in the sigmoid colon. An emergency laparotomy with sigmoid colotomy was undertaken to remove the obstructing gallstone, and the patient made a full recovery.
doi:10.1136/bcr.11.2011.5100
PMCID: PMC3279656  PMID: 22665402
24.  Cholecystoduodenocolic fistula and gallstone ileus. 
Postgraduate Medical Journal  1984;60(708):698-699.
A patient with cholecystoduodenocolic fistula and gallstone ileus is described. Barium enema and barium meal and follow through demonstrated the passage of the gallstone from the gallbladder region to the small bowel. The clinical features and operative management are discussed in the light of four previously recorded cases.
Images
PMCID: PMC2418044  PMID: 6494094
25.  Metastatic breast cancer presenting as a gallstone ileus 
Journal of Surgical Case Reports  2013;2013(12):rjt113.
Metastatic breast cancer to the small bowel (SB) presenting as gallstone ileus and resulting in SB obstruction has not been described previously. A 76-year-old woman with previous metastatic breast cancer to the axial spine and hips presented with abdominal pain and bilious vomiting. CT scanning revealed SB obstruction consistent with gallstone ileus. The patient underwent two segmental SB resections for distal ileal strictures mimicking what appeared to be macroscopic Crohn's disease. The entero-biliary fistula was undisturbed. Pathological analysis revealed the dual pathologies of gallstone ileus and metastatic carcinoma from a breast primary causing luminal SB obstruction. Improvements in staging and treatment modalities have contributed to the increased overall long-term survival for breast cancer, compelling clinicians to consider metastatic breast cancer as a differential diagnosis in women presenting with new onset of gastrointestinal symptoms in order that appropriate treatment be administered in a timely fashion.
doi:10.1093/jscr/rjt113
PMCID: PMC3888007

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