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Gallstone Ileus

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  • • Small bowel obstruction secondary to 1 or more large gallstones entering via cholecystoduodenal fistula

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Mirizzi Syndrome

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  • • Biliary stricture secondary to direct compression by chronically impacted cystic duct gallstone or chronic inflammation secondary to chronically inflamed gallbladder

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Epidemiology

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  • • Both gallstone ileus and Mirizzi syndrome are rare complications mainly affecting patients older than 60 years

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Symptoms and Signs

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Gallstone Ileus

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  • • Signs and symptoms of small bowel obstruction and possible antecedent history of biliary colic

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Mirizzi Syndrome

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  • • Chronic or history of right upper quadrant pain along with jaundice

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Laboratory Findings

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Gallstone Ileus

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  • • Hypokalemia

    • Prerenal azotemia

    • Hypernatremia

    • Leukocytosis

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Mirizzi Syndrome

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  • • Hyperbilirubinemia

    • Elevated alkaline phosphatase

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Imaging Findings

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Gallstone Ileus

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  • Abdominal x-ray

    • -Air-fluid levels

      -Dilated loops of small bowel

      -Possible pneumobilia

    US

    • -Cholelithiasis and pneumobilia

    Hypaque swallow

    • -Fistula between duodenum and gallbladder

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Mirizzi Syndrome

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  • US

    • -Biliary dilatation (> 6 mm)

      -Cholelithiasis

      -Possible thickened wall of gallbladder

    • ERCP or percutaneous transhepatic cholangiogram (PTC)

    • -Stricture of common bile duct

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Gallstone Ileus

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  • • Overall clinical status of patient

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Mirizzi Syndrome

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  • • Evaluate for malignant causes of stricture

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Gallstone Ileus

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  • • History and physical exam

    • CBC

    • Electrolytes

    • Blood urea nitrogen, creatinine

    • Plain abdominal x-ray

    • Right upper quadrant US

    • Small bowel contrast study if partial small bowel obstruction

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Mirizzi Syndrome

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  • • History and physical exam

    • CBC

    • Liver function tests

    • Right upper quadrant US

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Surgery

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Gallstone Ileus

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  • • Removal of retained small bowel gallstone(s) via enterostomy or partial resection if bowel damaged

    • Cholecystectomy and resection of fistula and duodenal closure at same operation or as staged procedure

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Mirizzi Syndrome

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  • • Cholecystectomy and resection and/or bypass of stricture via hepaticojejunostomy

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Contraindications

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  • • Clinical status of patient during laparotomy for gallstone ileus

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Complications

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Gallstone Ileus

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  • • Missed enteral gallstone and recurrent obstruction

    • Duodenal leak

    • Bile duct injury or leak

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Mirizzi Syndrome

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  • • Anastomotic leak or stricture

    • Cholangitis

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References

Glasgow RE et al: The spectrum and cost of complicated gallstone disease in California. Arch Surg 2000;135:1021.  [PubMed: 10982504]
Berber E et al: Selective use of tube cholecystostomy with interval laparoscopic cholecystectomy in acute cholecystitis. Arch Surg...

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