Hospital: Complejo Hospitalario Universitario de Badajoz, Complejo Hospitalario Universitario de Badajoz.
Aut@r o Autores: P. Fernández Tejado, S. Fernández Gomez, A. Lopez Moreno, M. Relaño Mesa, G. Rueda Monago, F. Alonso Ávalos.
71 years old woman consulted our primary care emergency service with pain at right hypochondrium and epigastrium, bilious vomits and oral intorelance. Cholecystitis was diagnosed 8 months ago, but she hasn´t been operated yet. Recent weight loss, anorexia, early satiety has been referred as well. Rx. Gastric distension and dilated bowel loops. CT. We could see abnormal gallbladder with irregular wall, gallstones´s presence and air-fluid level. Pricholecystic inflammatory changes extending into the duodenum and a cholecystoduodenal fistula could be seen. Small bowel obstruction with a 4 cm segment of ileum as a transition point, where we could see an ectopic gallstone. There were no signs of ischemia intestinal, free gas, portal venous gas or mural gas.
Although overall gallstone ileus is an uncommon cause of small bowel obstruction (14% ), in the elderly is not uncommon, and accounts for up to 25% of non-strangulated bowel obstructions. The etiology of gallstone ileus results from adhesions forming between an inflamed gallbladder and an adjacent GI tract followed by gallstones causing pressure necrosis or inflammation between the two tissues. Gallstones can move from the gallbladder to the GI tract through this direct access. The site of fistula formation, size of gallstone, and size of bowel lumen will determine the location of impaction. Fistulous communication: Cholecystoduodenal (60%), Choledochoduodenal, cholecystocolic, choledochoclolic, cholecystogastric. Rigler triad (15% to 50% of patients).consists of three findings seen in gallstone ileus: - Pneumobilia. - Small bowel obstruction. - Ectopic gallstone The differential diagnosis CT is that of each component of Rigler triad: - Lowel abdominal/ pelvic calcification. - Small bowel obstruction (other causes). Contrast-enhanced CT allows detection of edema and ischemia of the affected gastrointestinal tract site.
Gallstone ileus is a rare complication of cholelithiasis and is one of the rarest forms of all mechanical bowel obstructions. The diagnosis is often delayed since symptoms may be intermittent and investigations may fail to identify the cause of the obstruction. As a result, gallstone ileus continues to be associated with relatively high rates of morbidity and mortality, so the radiology is now the key diagnostic tool.
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