Case Report Perforated Closed-Loop Obstruction Secondary to … · 2019. 7. 31. · residual gallbladder bed to create a controlled biliary ... having the greatest diagnostic accuracy

Case ReportPerforated Closed-Loop Obstruction Secondary to GallstoneIleus of the Transverse Colon: A Rare Entity

S. P. Carr,1 F. T. MacNamara,1,2 K. M. Muhammed,2 E. Boyle,1,2

S. M. McHugh,1,2 P. Naughton,1,2 and A. Leahy1,2

1Royal College of Surgeons in Ireland, Dublin 2, Ireland2Department of Surgery, Beaumont Hospital, Dublin 17, Ireland

Correspondence should be addressed to S. P. Carr; [email protected]

Received 7 November 2014; Accepted 11 January 2015

Academic Editor: Fernando Turégano

Copyright © 2015 S. P. Carr et al.This is an open access article distributed under the Creative Commons Attribution License, whichpermits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Introduction. Gallstone ileus (GSI) of the colon is an extremely rare entity with potentially serious complications includingperforation. Case Presentation. An 88-year-old man presented to the emergency department with abdominal pain and distension.Clinical exam revealed signs of peritonism. Computed tomography (CT) revealed GSI of the transverse colon with a closed-looplarge bowel obstruction (LBO) and caecal perforation. The patient underwent emergency laparotomy. A right hemicolectomy wasperformed, the gallstone was removed, and a primary bowel anastomosis was undertaken. A Foley catheter was sutured into theresidual gallbladder bed to create a controlled biliary fistula. The patient recovered well postoperatively with no complications.He was discharged home with the Foley catheter in situ. Discussion. Gallstone ileus is a difficult diagnosis both clinically andradiologically with only 50% of cases being diagnosed preoperatively. Most commonly it is associated with impaction at theileocaecal valve and small bowel obstruction. Gallstone ileus should also be considered as a rare but potential cause of LBO.This isthe first reported case of caecal perforation secondary to gallstone ileus of the transverse colon. Successful operative managementconsisted of a one-stage procedure with right hemicolectomy and formation of a controlled biliary fistula.

1. Introduction

Most common mechanical bowel obstruction due to agallstone occurs at the ileocaecal valve due to the reduceddiameter and reduced active peristalsis [1]. This has beenreported as being associated with jejunal perforation [2, 3].

Colonic obstruction due to a gallstone occurs rarely [4, 5].The obstructing stone needs tomeasure at least 5 cm in diam-eter or larger than 2.5 cm with concurrent bowel pathology[6–8]. Colonic perforation in this setting is rare with onlythree previous reported cases of sigmoid perforation. This isthe first reported case of perforation secondary to gallstoneileus (GSI) of the transverse colon resulting in close-looplarge bowel obstruction (LBO).

2. Case Report

An88-year-oldman presented to the EmergencyDepartmentin a tertiary Irish hospital with abdominal pain anddistension

having being referred by his general practitioner. His symp-toms had occurred three days prior to presentation. Therewas no associated nausea or vomiting. The patient had noprevious medical or surgical history and was on no regularmedications. He had no previous known history of gallstones.

An abdominal X-ray and erect chest X-ray wererequested. His abdominal X-ray revealed a distended largebowel with a collapsed small bowel (Figure 1). His chestX-ray revealed free intraperitoneal air visible under thediaphragm (Figure 2). Computed tomography (CT) scanof the abdomen and pelvis was performed. This revealeda close-loop LBO at the level of the transverse colon, withcaecal distention to 10 centimetres, pneumatosis of the caecalwall, and free intraperitoneal air and fluid consistent withenteral perforation. The patient was subsequently scheduledfor emergency laparotomy.

The patient underwent a vertical midline laparotomy.Theright colon was noted to be grossly distended with caecalischemia and perforation. A seven-centimetre gallstone was

Hindawi Publishing CorporationCase Reports in SurgeryVolume 2015, Article ID 691713, 4 pageshttp://dx.doi.org/10.1155/2015/691713

2 Case Reports in Surgery

Figure 1: Abdominal X-ray revealing distended large bowel with acollapsed small bowel.

Figure 2: Chest X-ray revealing free intraperitoneal air under thediaphragm.

noted to be causing obstruction at the proximal third of thetransverse colon, where a cholecystocolic fistula communi-cating between the transverse colon and the gallbladder wasidentified (Figures 3, 4, and 5). The decision was taken toperform a right hemicolectomy that was performed from theterminal ileum to healthy transverse colon. A primary side-to-side stapled anastomosiswas performed.Due to the degreeof inflammation around the gallbladder and duodenum acomplete cholecystectomy was not performed. A controlledfistula from the gallbladder bed to the skin was createdvia the insertion of a Foley catheter through a separateupper abdominal incision. Five millilitres of sterile water wasinflated into the Foley catheter balloon, and a purse-stringsuture was used on the gallbladder wall around the catheterto hold the balloon in the gallbladder bed. A completeabdominal washout was performed and two Robinson drainswere placed via separate incisions in the abdominal cavity.

Postoperatively the patient recovered well. The patientrecommenced oral intake day three postoperatively andcompleted a ten-day course of intravenous antibiotics.Hewasdischarged home with the Foley catheter in situ, where it wassubsequently removed in surgical outpatients.

Figure 3: Photograph of the large 7 cm gallstone removed from thetransverse colon.

Figure 4: Intraoperative picture showing 7 cm gallstone causingobstruction at the proximal third of the transverse colon, with acholecystocolic fistula communicating between the transverse colonand the gallbladder.

Figure 5: Intraoperative picture showing 7 cm gallstone beingremoved from the transverse colon.

Case Reports in Surgery 3

3. Discussion

It is acknowledged that GSI is a difficult diagnosis bothclinically and radiologically with only 50% of cases beingdiagnosed preoperatively [9]. Only 50% of patients pre-senting with GSI have a history of gallstones or biliarypathology [10]. Considering the high mortality rate (15–18%)[1] associated with GSI, prompt diagnosis and appropriatesurgical management are essential for a favorable outcome.

With regard to imaging techniques, CT is recognized ashaving the greatest diagnostic accuracy with a sensitivity of93% and specificity of 100% [11]. In an emergency setting CTprovides a more rapid and accurate diagnosis [12] and alsoallows for a better determination of the degree of obstruction,its location and visualisation of bilioenteric fistulae, and thecondition of the adjacent bowel mucosa. Despite the numberof modern radiological diagnostic modalities GSI involvingthe colon is such a rarity diagnosis is still most oftenmade onlaparotomy [13].

Debate exists regarding surgical options for GSI caus-ing uncomplicated small bowel obstruction. Enterotomyalone with removal of the obstructing gallstone alone withexpectant management is regarded as the most appropriatesurgical management in an emergency setting [1, 9]. Single-stage surgery comprises a combination of enterolithotomy,cholecystectomy, and fistulotomy. Enterotomy alone is asso-ciated with a lower mortality rate (11.7%) when compared tosingle-stage surgery (16.9%). With regard to intraoperativefistula management, there is a low rate of further compli-cations reported as a result of not performing a fistulotomyat primary surgery with only 5% recurrence rate of GSI.Furthermore, only 10% of patients require further surgeryfor persistent biliary symptoms [1]. In this case, however,in order to treat the caecal perforation a right colectomywas performed necessitating the operative treatment of thecholecystocolic fistula.

There is a paucity of reported cases involving colonicperforation. In 2009, van Kerschaver et al. reported onGSI causing necrosis and perforation of the rectosigmoidjunction. A Hartmann’s procedure was performed to treatthe perforation and the obstruction. A subsequent chole-cystectomy and closure of the cholecystocolonic fistula wereplanned to be performed at the time of restoration ofthe intestinal continuity [14]. D’Hondt and Schoofs alsoreported on the surgical management of sigmoid perforationsecondary to GSI in 2011 and 2010, respectively [15, 16].All of these previous cases report on GSI causing pressure-related perforation at the site of obstruction. Our case isunique in that we report the surgical management of aremote perforation of the caecum as a result of GSI causingLBO. Furthermore, octogenarians may have an incompetentileocecal valve which would negate the evolution of a closed-loop obstruction. This was not the case in our reportedpatient. Successful patient outcome was achieved throughprompt preoperative diagnosis and successful single-stagesurgery involving right hemicolectomy and controlled biliaryfistula formation.

4. Conclusion

Gallstone ileus causing a LBO is a rare entity, and casesinvolving colonic perforation are rarer still. Previous reportedcases have demonstrated colonic perforation at the site ofmechanical obstruction. We report on a closed-loop LBOleading to remote perforation secondary to GSI at the trans-verse colon. Successful management included right hemi-colectomy and controlled biliary fistula formation. Gallstoneileus should be considered in patients as a potential cause ofbowel obstruction, even without previously known history ofgallstones.

Conflict of Interests

The authors declare that there is no conflict of interestsregarding the publication of this paper.

References

[1] R. M. Reisner and J. R. Cohen, “Gallstone ileus: a review of 1001reported cases,” The American Surgeon, vol. 60, no. 6, pp. 441–446, 1994.

[2] L. E. Browning, J. D. Taylor, S. K. Clark, and N. D. Karanjia,“Jejunal perforation in gallstone ileus—a case series,” Journal ofMedical Case Reports, vol. 1, article 157, 2007.

[3] M. Gupta, S. Goyal, R. Singal, R. Goyal, S. Goyal, and A. Mittal,“Gallstone ileus and jejunal perforation along with gangrenousbowel in a young patient: a case report,”North American Journalof Medical Sciences, vol. 2, no. 9, pp. 442–443, 2010.

[4] H. Fjermeros, “Gall-stone ileus. Case reports and review of178 cases from Scandinavia and Finland,” Acta ChirurgicaScandinavica, vol. 128, pp. 186–192, 1964.

[5] H. L. Foss and J. Summers, “Intestinal obstruction from gall-stones,”Annals of Surgery, vol. 115, no. 5, pp. 721.b2–735.b2, 1942.

[6] G. W. Buetow and R. S. Crampton, “Gallstone ileus. A report of23 cases,” Archives of surgery, vol. 86, pp. 504–511, 1963.

[7] P. Holm-Nielsen and P. Linnet-Jepsen, “Colon obstructioncaused by gallstones,”Acta Chirurgica Scandinavica, vol. 107, no.1, pp. 31–40, 1954.

[8] W. V. Young Jr., “Gallstone ileus of the colon. Report of anunusual type of colon obstruction,” Archives of Surgery, vol. 82,pp. 333–336, 1961.

[9] A. A. Ayantunde and A. Agrawal, “Gallstone ileus: diagnosisand management,” World Journal of Surgery, vol. 31, no. 6, pp.1294–1299, 2007.

[10] W. Kirchmayr, G. Mühlmann, M. Zitt, J. Bodner, H. Weiss, andA. Klaus, “Gallstone ileus: rare and still controversial,” ANZJournal of Surgery, vol. 75, no. 4, pp. 234–238, 2005.

[11] C. Y. Yu, C. C. Lin, R. Y. Shyu et al., “Value of CT in thediagnosis and management of gallstone ileus,”World Journal ofGastroenterology, vol. 11, no. 14, pp. 2142–2147, 2005.

[12] J.-W. Chou, C.-H. Hsu, K.-F. Liao et al., “Gallstone ileus: reportof two cases and review of the literature,” World Journal ofGastroenterology, vol. 13, no. 8, pp. 1295–1298, 2007.

[13] D. N. Lobo, J. C. Jobling, and T. W. Balfour, “Gallstone ileus:diagnotic pitfalls and therapeutic successes,” Journal of ClinicalGastroenterology, vol. 30, no. 1, pp. 72–76, 2000.

[14] O. van Kerschaver, V. van Maele, L. Vereecken, and M. Kint,“Gallstone impacted in the rectosigmoid junction causing a

4 Case Reports in Surgery

biliary ileus and a sigmoid perforation,” International Surgery,vol. 94, no. 1, pp. 63–66, 2009.

[15] M. D’Hondt, A. D’Haeninck, and F. Penninckx, “Gallstoneileus causing perforation of the sigmoid colon,” Journal ofGastrointestinal Surgery, vol. 15, no. 4, pp. 701–702, 2011.

[16] C. Schoofs, R. Vanheste, L. Bladt, and F. Claus, “Cholecysto-colonic fistula complicated by gallstone impaction and perfo-ration of the sigmoid,” JBR-BTR, vol. 93, no. 1, p. 32, 2010.

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Case Report Perforated Closed-Loop Obstruction Secondary to … · 2019. 7. 31. · residual gallbladder bed to create a controlled biliary ... having the greatest diagnostic accuracy