Case of stone in small intestine.. Enterostomy and lithoextraction done..

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At laparotomy, a longitudinal enterotomy is made along the antimesenteric border proximal to the point of impaction [3]. The stone is milked proximally and removed. Careful transverse closure of the enterotomy is required to avoid residual bowel stenosis. Manipulation of stones through the cecum has been associated with mucosal injury and undetected serosal rupture, and therefore should not be performed routinely [9]. The entire bowel should be carefully inspected for more gallstones, which occur in 3 to 16 percent of cases. These can be removed by milking the gut, thereby moving smaller stones towards bigger ones. Faceted or cylindrical gallstones are considered to increase the likelihood of multiple stones being present
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Gallstone ileus is an important, though infrequent, cause of mechanical bowel obstruction, affecting older adult patients who often have other significant medical conditions. It is caused by impaction of a gallstone in the ileum after being passed through a biliary-enteric fistula. The diagnosis is often delayed since symptoms may be intermittent and investigations fail to identify the cause of the obstruction. The mainstay of treatment is removal of the obstructing stone after resuscitating the patient. Gallstone ileus continues to be associated with relatively high rates of morbidity and mortality.
The classic clinical presentation of gallstone ileus is in an older woman with episodic subacute obstruction. The episodic obstruction or "tumbling obstruction" is a result of the stone tumbling through the bowel lumen. Transient gallstone impaction produces diffuse abdominal pain and vomiting, which subside as the gallstone becomes disimpacted, only to recur again as the stone lodges in the more distal bowel lumen. As a result, vague and intermittent symptoms may be present for some days prior to evaluation. The mean symptom duration before hospital admission is approximately five days
Diagnosis by CECT abdomen.●Gallbladder wall thickening ●Pneumobilia ●Intestinal obstruction ●Obstructing gallstones Pneumobilia occurs in 30 to 60 percent of patients with gallstone ileus but is a nonspecific finding. Air can enter the biliary tree from the gastrointestinal tract via a patent cystic duct or enterobiliary fistula. Alternatively, air in the biliary tree can also result from an incompetent sphincter of Oddi or prior biliary procedure/surgery
one-stage procedure includes enterolithotomy, cholecystectomy, and biliary-enteric fistula closure, with an optional common bile duct exploration. Compared with enterolithotomy alone, the one-stage procedure reduces recurrences of gallstone ileus; prevents malabsorption and weight loss from a persistent biliary-enteric fistula; and prevents cholecystitis, cholangitis, and gallbladder carcinoma, but at the risk of higher surgical morbidity and mortality
The Mirizzi syndrome refers to common hepatic duct obstruction caused by an extrinsic compression from an impacted stone in the cystic duct. An association between the Mirizzi syndrome and the presence of a cholecystoenteric fistula has been suggested because when a stone is impacted in the cystic duct it can result in narrowing of the common hepatic duct, which can lead to a cholecystenteric fistula thus providing an exit route for gallstones
The treatment for gallstone ileus is primarily surgical. Gallstone ileus involves three key elements, cholelithiasis, biliary-enteric fistula, and intestinal obstruction. Intestinal obstruction is typically addressed with an enterolithotomy (ie, enterotomy with stone removal). Cholelithiasis and biliary-enteric fistula are typically addressed together with a combined biliary procedure involving cholecystectomy and fistula closure.
Rarely, the gallstone becomes impacted within the pyloric channel or duodenum, causing gastric outlet obstruction (Bouveret’s syndrome). The offending stone travels from the biliary tree via a cholecystoduodenal fistula, formed in the setting of cholecystitis and pericholecystic inflammation. The presenting symptoms are abrupt onset of epigastric pain, nausea, and vomiting.
Gallstone ileus results in obstruction if the gallstone is of large enough size. Ninety percent of obstructing stones are greater than 2 cm in diameter, with the majority measuring over 2.5 cm [8]. Fifty to 70 percent of gallstones impact in the ileum, which is the narrowest segment of the intestine. The jejunum and stomach are the next most frequently affected sites
The following sequence is probably responsible for most cases of fistula formation that lead to gallstone ileus. Pericholecystic inflammation after cholecystitis leads to the development of adhesions between the biliary and enteric systems. Pressure necrosis by the gallstone against the biliary wall then causes erosion and fistula formation.
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