Cholelithiasis, Rare Complications

Gallstone Ileus

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

Mirizzi Syndrome

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

Epidemiology

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

Symptoms and Signs

Gallstone Ileus

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

Mirizzi Syndrome

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

Laboratory Findings

Gallstone Ileus

• • Hypokalemia

  • Prerenal azotemia

  • Hypernatremia

  • Leukocytosis

Mirizzi Syndrome

• • Hyperbilirubinemia

  • Elevated alkaline phosphatase

Imaging Findings

Gallstone Ileus

• • Abdominal x-ray

  • -Air-fluid levels

    -Dilated loops of small bowel

    -Possible pneumobilia

  • US

  • -Cholelithiasis and pneumobilia

  • Hypaque swallow

  • -Fistula between duodenum and gallbladder

Mirizzi Syndrome

• • US

  • -Biliary dilatation (> 6 mm)

    -Cholelithiasis

    -Possible thickened wall of gallbladder

  • ERCP or percutaneous transhepatic cholangiogram (PTC)

  • -Stricture of common bile duct

Gallstone Ileus

• • Overall clinical status of patient

Mirizzi Syndrome

• • Evaluate for malignant causes of stricture

Gallstone Ileus

• • 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

Mirizzi Syndrome

• • History and physical exam

  • CBC

  • Liver function tests

  • Right upper quadrant US

Surgery

Gallstone Ileus

• • 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

Mirizzi Syndrome

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

Contraindications

• • Clinical status of patient during laparotomy for gallstone ileus

Complications

Gallstone Ileus

• • Missed enteral gallstone and recurrent obstruction

  • Duodenal leak

  • Bile duct injury or leak

Mirizzi Syndrome

• • Anastomotic leak or stricture

  • Cholangitis

References