Bile ileus as a rare cause of obstructive acute abdomen, clinical case presentation

Abstract

Introduction: Gallstone ileus is an infrequent complication of cholelithiasis (0.3-0.5%) and it is also a cause of
mechanical obstruction of the small or large intestine, which is caused by the migration of a stone through a
bilioenteric fistula itself that is more frequently cholecystoduodenal (65-77%) and that, despite being able to
lodge in any part of the path, it most commonly lodges in the terminal ileum due to its anatomical narrowness.
Although its prevalence is low of only 1-4% of the total of mechanical obstructive intestinal pathologies, this
pathology is found in older adult patients and women, these being 25% of the total cases of the same and
presents a mortality rate of 12- 27% and reaching a recurrence of up to 50% of the same, which is why its
diagnostic suspicion is of vital importance, together with the importance of image diagnosis and finally its
initial surgical treatment, which in turn is also controversial between a single-step surgery with a higher
mortality rate and a two-step surgery with less mortality than the previous one but with a higher rate of
persistence of cholecystoenteric fistula, recurrence of pathology and also the risk of carcinogenesis.

Objective: To carry out a bibliographic review on the clinical suspicion of gallstone ileus, as well as its
surgical management, and to exemplify it by presenting a clinical case.

Material and methods: Descriptive, retrospective study, presentation of a clinical case in the "IESS Latacunga
Basic Hospital", a case that was treated in the General Surgery service of the hospital.

Results: Description of the clinical case: a 29-year-old female patient with a personal clinical history of
hypertriglyceridemia treated with gemfibrozil; cholelithiasis diagnosed without treatment; grade III obesity;
allergies: does not refer; surgical history: does not refer. Gyneco-obstetric history of importance: Date of last
menstruation on 05/20/2007, refers to the use of family planning based on norethisterone + ethinyl estradiol.
Current disease: Patient reported that 24 hours before going to the consultation, he presented without apparent
cause colic-type abdominal pain of moderate intensity, located in the epigastrium with diffuse radiation to the
flanks, this pain was accompanied by nausea that reached vomiting on more than 20 occasions. at the
beginning of nutritional content, but later becoming bilious. Despite episodes of vomiting, abdominal pain did
not subside, and she did not present any other symptoms. At the time of going to the medical consultation, a
physical examination was performed that reported a globose abdomen at the expense o f adipose panniculus
without scars, painful on superficial and deep palpation in the epigastrium and left hypochondrium without
the presence of visceromegaly and positive signs of peritoneal reaction. metallic airborne noises, increased in
tone and strength; Rectal examination was also performed where tonic sphincter, empty rectal ampoule,
without masses and clean glove finger were found. Complementary imaging tests are performed where
Rigler's Triad is identified, compatible with a gallstone ileus. Emergency surgical intervention is decided.

Conclusions: Gallstone ileus is an important and infrequent cause of mechanical obstruction and its
knowledge by the surgeon is essential for a diagnosis as early as possible.