Gallstone ileus is a rare cause of bowel obstruction, which mainly affects the elderly population. The associated mortality is estimated to be up to 30%. The presentation of gallstone ileus is notoriously non-specific, and this often contributes to the delay in diagnosis. The diagnosis of gallstone ileus relies on a radiological approach, and herein we discuss the benefits and drawbacks of the use of different modalities of radiological imaging: plain abdominal films, computed tomography, magnetic resonance imaging, and ultrasound scanning. Based on our case experience and review of the literature, the authors conclude that although an effective first-line tool, plain abdominal films are not adequate for diagnosing gallstone ileus. In fact, the gold standard in an acutely unwell patient is computed tomography.

/pdf/clinical-and-radiological-diagnosis-of-gallstone-ileus-a-1xtzl89fgy.pdf

Clinical and radiological diagnosis of gallstone ileus: a mini review.

Small bowel obstruction (SBO) accounts for 12-16% of emergency surgical admissions and 20% of emergency surgical procedures. Even with the advent of laparoscopic surgery, intra-abdominal adhesions remain a significant cause of SBO, accounting for 65% of cases. History and physical examination are essential to identify signs of bowel ischemia as this indicates a need for urgent surgical exploration. Another critical aspect of evaluation includes establishing the underlying cause for obstruction and distinguishing between adhesive and non-adhesive etiologies as adhesive SBO (ASBO) can be managed non-operatively in 70-90% of patients. A patient with a history of abdominopelvic surgery along with one or more cardinal features of obstruction should be suspected to have ASBO until proven otherwise. Triad of severe pain, pain out of proportion to the clinical findings, and presence of an abdominal scar suggest possible closed-loop obstruction. Computed tomography has higher sensitivity and specificity compared to plain films and is recommended by the Bologna guidelines. Correcting fluid and electrolyte imbalance is an initial crucial step to mitigate severe hypovolemia. Patients should proceed with surgery if symptoms of bowel compromise are present, or if symptoms do not resolve or have worsened. Surgery is indicated in patients with ischemia, strangulation, perforation, peritonitis, or failure of non-operative treatment. With advances in minimal access technology and increasing experience, laparoscopic adhesiolysis is recommended. Mechanical adhesion barriers are an effective measure to prevent adhesion formation.

https://onlinelibrary.wiley.com/doi/pdf/10.1002/ams2.587

Adhesive small bowel obstruction - an update.

Background: Gallstone or biliary ileus is a late complication of gallstone disease. It accounts for 1%–4% of all bowel obstructions and is more common in elderly patients. The preferred treatment option is to mechanically remove the impacted stones. It is done surgically using open or laparoscopic approach and rarely, when stones are impacted in the colon, endoscopically. In this paper we present five consecutive cases of gallstone ileus and describe possible diagnostic and minimally invasive treatment options. Case presentation: During a five-month period a total of five patients were treated for gallstone ileus. All patients were female and from 48 to 87 years of age. Symptoms were not specific and common for all small bowel obstructions. Upon admission the patients also had unspecific laboratory findings—neutrophilic leukocytosis and various C-reactive protein concentrations, ranging from 8 to 347 mg/L. According to the hospital protocol, all patients initially underwent an abdominal ultrasound, which was inconclusive, and therefore every patient additionally had a CT scan with intravenous contrast. After these two diagnostic modalities one patient still did not have the definitive gallstone ileus diagnosis, as the ectopic stone was not visible. Four patients in our case series were treated using minimally invasive methods: in one case the stone was removed endoscopically, and laparoscopically in the other three. Treatment outcomes were good in four cases as the patients fully recovered, however one patient suffered a massive cerebral infarction after the operation and passed away. Conclusions: Gallstone ileus is a rare and difficult-to-diagnose condition. Management of these patients in every case should be individualized, as there are many options, each with their own advantages and disadvantages. We show that minimally invasive treatment such as colonoscopy or laparoscopy is possible in these cases.

https://epublications.vu.lt/object/elaba:50859095/50859095.pdf

Gallstone Ileus: Management and Clinical Outcomes

The lumbar abdominal wall hernia is a rare hernia in which abdominal contents protrude through a defect in the dorsal abdominal wall, which can be of iatrogenic, congenital, or traumatic origin. Two anatomical locations are known: the superior and the inferior lumbar triangle. The aim of this systematic review is to provide a clear overview of the existing literature and make practical clinical recommendations for proper diagnosis and treatment of the primary lumbar hernia. The systematic review was conducted according to the PRISMA guidelines. A systematic search in PubMed, MEDLINE, and EMBASE was performed, and all studies reporting on primary lumbar hernias were included. No exclusion based on study design was performed. Data regarding incarceration, recurrence, complications, and surgical management were extracted. Out of 670 eligible articles, 14 were included and additional single case reports were analysed separately. The average quality of the included articles was 4.7 on the MINORS index (0–16). Risk factors are related to increased intra-abdominal pressure. CT scanning should be performed during pre-operative workup. Available evidence favours laparoscopic mesh reinforcement, saving open repair for larger defects. Incarceration was observed in 30.8% of the cases and 2.0% had a recurrence after surgical repair. Hematomas and seromas are common complications, but surgical site infections are relatively rare. The high risks of incarceration in lumbar hernias demand a relatively fast elective repair. The use of a mesh is recommended, but the surgical approach should be tailored to individual patient characteristics and risk factors.

/pdf/pitfalls-and-clinical-recommendations-for-the-primary-lumbar-58gsj73td6.pdf

Pitfalls and clinical recommendations for the primary lumbar hernia based on a systematic review of the literature.

Lumbar hernias can be superior (Grynfelt) and inferior (Petit). Inferior lumbar hernias are extremely rare and, therefore, are associated with diagnostic difficulty. We present a case of a primary spontaneous inferior lumbar hernia in a 79-year-old woman that was initially diagnosed as a large lipoma on ultrasound. The first operation was abandoned and an open mesh repair was conducted. Lumbar hernias can be primary acquired (55%), secondary acquired (25%) or congenital (20%). Cross-sectional imaging by CT or MRI appears to be the gold standard in diagnosis as ultrasound may lead to misdiagnosis. Strangulation, incarceration and obstruction are recognised complications, requiring prompt surgical intervention. There are currently no guidelines for surgical managements, although laparoscopic surgery may give the best results. In view of the scarcity of published cases, we aim to add to the literature to raise the index of suspicion and to promote prompt surgical management of lumbar hernias.

/pdf/a-primary-inferior-lumbar-hernia-misdiagnosed-as-a-lipoma-4kf9o6a1we.pdf

A primary inferior lumbar hernia misdiagnosed as a lipoma.

Introduction Gallstone ileus represents 4% of the causes of bowel obstruction in the general population, but increases to 25% in patients above the age of 65 years Gallstone ileus does not present with unique symptoms, making diagnosis difficult Its management is surgical, but there is no consensus as to which of the different surgical techniques is the procedure of choice At present, there is no recent review of this pathology Aim To conduct an up-to-date review of this disease Materials and methods Articles published within the time frame of 2000 to 2014 were found utilizing the PUBMED, EMBASE, and Cochrane Library search engines with the terms “gallstone ileus” plus “review” and the following filters: “review”, “full text”, and “humans” Results The results of this review showed that gallstone ileus etiology was due to intestinal obstruction from a gallstone that migrated into the intestinal lumen through a bilioenteric fistula The presence of 2 of the 3 Rigler's triad signs was considered diagnostic Abdominal tomography was the imaging study of choice for gallstone ileus diagnosis and the surgical procedures for management were enterolithotomy, one-stage surgery, and two-stage surgery Enterolithotomy had lower morbidity and mortality than the other 2 procedures Conclusions The aim of gallstone ileus treatment is to release the obstruction, which is done through enterolithotomy It is the recommended technique for gallstone ileus management because of its lower morbidity and mortality, compared with the other techniques

Gallstone ileus: An overview of the literature.

Resumen Introduccion El ileo biliar representa el 4% de las causas de obstruccion intestinal en la poblacion general, pero incrementa a un 25% en los pacientes mayores a los 65 anos de edad. El ileo biliar no presenta sintomas unicos, haciendo dificil su diagnostico. Su manejo es quirurgico, pero no hay consenso sobre cual de las diferentes tecnicas quirurgicas es el procedimiento de eleccion. Actualmente, no hay una revision reciente de esta patologia. Objetivo Llevar a cabo una revision actualizada de esta enfermedad. Materiales y metodos Los articulos publicados dentro del periodo 2000-2014 se encontraron utilizando los motores de busqueda PUBMED, EMBASE, y la Cochrane Library utilizando los terminos «gallstone ileus» mas «review» y los siguientes filtros fueron empleados: «review», «full text», y «humans». Resultados Los resultados de esta revision mostraron que la etiologia del ileo biliar se debio a la obstruccion intestinal ocasionada por un calculo biliar que migro hacia el lumen intestinal a traves de una fistula enterobiliar. La presencia de 2 de los 3 signos de la triada de Rigler se considero al momento de diagnostico. La tomografia abdominal fue el estudio de eleccion para el diagnostico del ileo biliar y los procedimientos quirurgicos para su manejo fueron la enterolitotomia, la cirugia en un solo tiempo, y la cirugia en dos tiempos. La enterolitotomia tenia una morbimortalidad menor que los otros dos procedimientos. Conclusiones El objetivo del tratamiento del ileo biliar es liberar la obstruccion, obtenido a traves de la enterolitotomia. Esta es la tecnica recomendada para el manejo del ileo biliar debido a su morbimortalidad menor, comparada con las otras tecnicas.

El íleo biliar: una revisión de la literatura médica

Introduction Lumbar hernia account for less than 2% of al abdominal hernias, been the Grynfelt-Lesshaft's hernia (GLH) more frequent than the others. With approximately 300 cases published in the literature, the general surgeon may have the chance of treat it ones in their professional life. Case report A 42-years old male with human immunodeficiency virus and Diabetes Mellitus presented to the outpatient clinic with a GLH. Preoperative classified as a type “A” lumbar hernia an open approach was scheduled. We performed a Sandwich technique with a sublay and onlay ULTRAPRO® mesh fixed with PDS® II suture without complications and discharged the patient 24-h after. After six months, the patient denied any complication. Discussion Primary (spontaneous) lumbar hernias represent 50–60% of all GLH. The preoperative classification of a lumbar hernia is mandatory to propose the best surgical approach. According to the classification of Moreno-Egea A et al., the best technique for our patient was an open approach. The Sandwich technique has demonstrated good outcomes in the management of the GLH. Conclusion The surgical approach should be according to the classification proposed and to the experience of the surgeon. The Sandwich technique has good outcomes.

L.F. de la Cerda-Trujillo

Papers

Gallstone ileus: An overview of the literature.

El íleo biliar: una revisión de la literatura médica

Grynfelt-Lesshaft hernia a case report and review of the literature

A rare case of a strangulated Littre's hernia with Meckel's diverticulum duplication. Case report and literature review.