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      Gallstone Ileus: Clinical Presentation and Radiological Diagnosis

      case-report
      1 , , 1
      ,
      Cureus
      Cureus
      rigler’s triad, gallstone ileus, gallstone diseases, abdominopelvic ct scan, intestinal obstrution

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          Abstract

          The term "gallstone ileus" refers to intestinal obstruction brought on by a gallstone lodged within its lumen. The gallstone travels through a fistula that develops because of the constant pressure it exerts on the gall bladder. The symptoms are vague and confounding which can commonly lead to delay in diagnosis. The preferred imaging technique is a computed tomography scan. The diagnosis is confirmed by the identification of Rigler's Triad on a CT scan, which includes a small intestinal obstruction, pneumobilia, and an ectopic stone in the intestine. The condition is associated with several complications and needs to be treated with emergency surgery. This case demonstrates how a patient could have non-specific symptoms and how early detection by imaging was crucial to the patient's treatment.

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          Gallstone ileus: a review of 1001 reported cases.

          Although rare in the general population, gallstone ileus accounts for 25 per cent of nonstrangulated small bowel obstructions in those over the age of 65. While mortality has declined over the years, it remains high at 15-18 per cent. This is largely due to the patient population, with comorbid medical conditions contributing to mortality. The proper extent of surgery continues to be actively debated. Proponents of minimal surgery feel that relief of the obstruction is all that is required. Others argue that the gallbladder and biliary-enteric fistula must be removed to prevent future recurrence (a one-stage procedure). The one-stage procedure carries an associated mortality of 16.9 per cent, compared to 11.7 per cent for simple enterolithotomy. Morbidity after enterolithotomy is low. The recurrence rate of gallstone ileus was less than 5 per cent, and only 10 per cent of patients required reoperation for continued symptoms related to the biliary tract. Simple enterolithotomy is both safe and effective in dealing with a patient with gallstone ileus.
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            Gallstone ileus: diagnosis and management.

            Gallstone ileus is a rare complication of cholelithiasis, mostly in the elderly. It accounts for 1%-4% of mechanical bowel obstruction and is associated with high morbidity and mortality. We present our experience of gallstone ileus and discuss current opinion as reported in the literature. A retrospective review was performed of medical records of patients in our institution coded for gallstone ileus by the International Classification of Diseases (ICD K-563) coding system between January 1998 and December 2005. There were 22 patients with mean age of 77 (58-92) years and a female to male ratio of 4.5:1. Most patients presented with abdominal pain and vomiting, with a median duration of symptoms of 3 (1-28) days. Preoperative diagnosis was made in 77% from a combination of plain x-ray, ultrasonography, and computed tomography (CT) scans; 86.4% of the patients belonged to ASA class of 3 or 4. Twenty patients underwent enterolithotomy alone, and two had one-stage procedure. The mean size of impacted stones was 3.6 (2.5-4.5) cm, with location in the terminal ileum in 17 and jejunum in 5 patients. There were 5 perioperative deaths and an episode of cholangitis occurring in one patient 18 months after enterolithotomy alone. Gallstone ileus is a difficult clinical entity to diagnose. Unreserved use of imaging techniques can improve diagnostic accuracy and speed of therapeutic decision making. Management of gallstone ileus must be individualized. The one-stage procedure should be offered only to highly selected patients with good cardiorespiratory reserve and with absolute indications for biliary surgery at the time of presentation.
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              Value of CT in the diagnosis and management of gallstone ileus.

              To retrospectively establish the diagnostic criteria of gallstone ileus on CT, and to prospectively apply these criteria to determine the diagnostic accuracy of CT to confirm or exclude gallstone ileus in patients who presented with acute small bowel obstruction (SBO). Another purpose was to ascertain whether the size of ectopic gallstones would affect treatment strategy. Fourteen CT scans in cases of proved gallstone ileus were evaluated retrospectively by two radiologists for the presence or absence of previously reported CT findings to establish the diagnostic criteria. These criteria were applied in a prospective contrast enhanced CT study of 165 patients with acute SBO, which included those 14 cases of gallstone ileus. The hard copy images of 165 CT studies were reviewed by a different group of two radiologists but without previous knowledge of the patient's final diagnosis. All CT data were further analyzed to determine the diagnostic accuracy of gallstone ileus when using CT in prospective evaluation of acute SBO. The size of ectopic gallstone on CT was correlated with the clinical course. The diagnostic criteria of gallstone ileus on CT were established retrospectively, which included: (1) SBO; (2) ectopic gallstone; either rim-calcified or total-calcified; (3) abnormal gall bladder with complete air collection, presence of air-fluid level, or fluid accumulation with irregular wall. Prospectively, CT confirmed the diagnosis in 13 cases of gallstone ileus with these three criteria. Only one false negative case could be identified. The remaining 151 patients are true negative cases and no false positive case could be disclosed. The overall sensitivity, specificity and accuracy of CT in diagnosing gallstone ileus were 93%, 100%; and 99%, respectively. Surgical exploration was performed in 13 patients of gallstone ileus with ectopic stones sized larger than 3 cm. One patient recovered uneventfully following conservative treatment with an ectopic stone sized 2 cm in the long axis. Contrast enhanced CT imaging offered crucial evidence not only for the diagnosis of gallstone ileus but also for decision making in management strategy.
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                Author and article information

                Journal
                Cureus
                Cureus
                2168-8184
                Cureus
                Cureus (Palo Alto (CA) )
                2168-8184
                18 July 2023
                July 2023
                : 15
                : 7
                : e42059
                Affiliations
                [1 ] Emergency Medicine, Leicester Royal Infirmary, Leicester, GBR
                Author notes
                Article
                10.7759/cureus.42059
                10356181
                a12e9fe3-4ec7-48af-b26b-7fea76da9838
                Copyright © 2023, Gaikwad et al.

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 18 July 2023
                Categories
                Emergency Medicine
                Radiology
                General Surgery

                rigler’s triad,gallstone ileus,gallstone diseases,abdominopelvic ct scan,intestinal obstrution

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