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home - Biliary - Gallstone Disease - Gallstone Ileus Written by Dr Sebastian Zeki

Knows the physiology and biochemistry of bile and the pathogenesis
of gallstones

Is familiar with the normal anatomy and the anatomical variations of
the biliary tree

Recognises the symptoms and signs of the potential complications of
galllstone disease including biliary colic acute cholecystitis jaundice
due to calculous bile duct obstruction cholangitis and carcinoma

Knows the various techniques of diagnostic imaging including
ultrasound CT MRI ERCP EUS radionuclide techniques

Knows the various treatment options the indications for operative and
non-operative management and the risks of each

Knows the current national guidelines for use of ERCP and the risks
of the technique

Knows the ways in which gallbladder polyps are diagnosed and

Knows that gallbladder and sphincter of Oddi dysfunction (SOD) may
account for otherwise unexplained abdominal pain

Recognises different types of SOD how they may present and how
they are investigated

Can select the most appropriate diagnostic and therapeutic
techniques for each clinical situation

Recognises possibility of diagnostic uncertainty in biliary dysmotility
and shows thoughtful judgement in each individual situation

Makes appropriate assessment stratifies urgency and plans
management of patients who have complications of gallstones

Gallstone Ileus

Enterolithotomy+/- biliary surgery.EnterolithotomyAntimesenteric border enterotomy made proximal to the point of impaction. Stone is milked proximally and removed (milking to caecum can cause serosal tears).Further stones occur in 10% of cases so whole gut to be inspected.Recurs in 17%.Cholecystectomy, and fistula division, with or without common bile duct (CBD) exploration (one-stage procedure), with definitive repair performed at a second operation (two-stage procedure)- for high risk. (This is the recommended diagnostic test)Signs of partial or complete intestinal obstruction Air in the biliary tree (pneumobilia)- 50 %-.Direct visualization of the stone Change in position of a previously located stone Two adjacent small bowel air-fluid levels in the right upper quadrant 2 of the first 3 findings in up to 50%.USSFistulas, impacted stones,residual cholelithiasis and choledocho-lithiasis.Gallbladder perforation but 50% sensitivityERCP Demonstrates fistula Bouveret's syndrome: gastric outlet obstruction due to gallstone impacted at pylorus/ duodenum Clinical Manifestations:-Episodic subacute obstruction in an elderly female.Symtpmos usually start around 5 day history before admission. Pathogenesis:Pericholecystic inflammation which results in biliary-enteric adhesions.Gallstone pressure necrosis against biliary wall with erosion and fistula formation.Gallstones get mixed with bowel contents to size increases. 90% of obstructing stones are >than 2 cm in diameter.60% of stones impact the ileum (narrowest part of the intestine)The jejunum and stomach are the next most frequent. Gallstone Ileus Abdominal CT scanningGallbladder thickeningPneumobiliaIntestinal obstructionObstructing gallstones Diagnosis IncidenceIt is < 0.5%.It accounts for2% of mechanical obstruction.It accounts for 25% of nonstrangulated small bowel obstruction in >65yrs.Av age is 70.It is 10x more common in females. Treatment:= Abdominal XR findings Written by Dr Sebastian Zeki

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