Gallstone Ileus with Resolution of Bile Leak Post-Subtotal Cholecystectomy and Spontaneous Closure of Cholecystoduodenal Fistula: Case Report and Literature Review

Gallstone ileus (GSI) is a mechanical intraluminal bowel obstruction caused by biliary calculi through the biliary-enteric fistula. This is a rare sequela of cholelithiasis occurring in 0.3 – 1.5% of patients with worrying mortality of 11.7 – 20%. This is a case of GSI in a 67-year-old woman who presented with small bowel obstruction secondary to impaction of biliary calculi at terminal ileum with underlying cholecystoduodenal fistula (CDF). Enterolithotomy with stone extraction (ES) was performed, followed by subtotal reconstituting cholecystectomy due to iatrogenic gallbladder perforation. The diagnosis of GSI is ascertained by the presence of the Rigler’s triad on abdominal X-ray, while CDF was demonstrated by post-surgery CT images. Bile leak post-operation was managed conservatively based on the SNAP (Sepsis, Nutrition, Anatomy, Plan) approach, and spontaneous closure of CDF was observed. In a nutshell, GSI should always be kept in mind as a differential diagnosis of mechanical bowel obstruction, especially among elderly female patients. Radiological findings of Rigler’s triad aid clinical diagnosis of GSI. Despite its rare incidence, early diagnosis is crucial as it is readily treatable with surgery. ES alone is the gold standard in the management of GSI.

Development a Nomogram for Predicting Intrahepatic Cholangiocarcinoma in Patients with Biliary Calculi after Surgery

Objective: To find out the risk factors of intrahepatic cholangiocarcinoma ( ICC ) in patients who underwent biliary surgery for biliary calculi, and to develop a nomogram to better predict the occurrence of ICC.Methods: Data were collected and analyzed retrospectively from 322 patients who underwent biliary tract surgery for biliary calculi in the First Affiliated Hospital of Wenzhou Medical University from January 2000 to December 2017.Of these patients, 58 patients had biliary calculi complicated with ICC while the other 294 patients had simple biliary calculi. Both univariate and multivariate analyses were performed to find out the risk factors related to ICC, and a nomogram was further developed based on the results of multivariate analysis.Results: The univariate analysis showed that there were significant differences in age composition (≤ 60 years old, > 60 years old), liver cirrhosis, stone history and previous hepatitis B infection (HBsAg- and HBcAb+) between the two groups. Logistic regression analysis indicated that liver cirrhosis (OR=2.011, 95%CI=1.023-3.952), stone history (OR=1.086, 95%CI=1.051-1.112) and age > 60 (OR=2.045, 95%CI=1.059-3.948) were the risk factors of ICC, while previous hepatitis B infection (HBsAg- and HBcAb+) (OR=0.461, 95%CI=0.215-0.989) was the protective factor. After drawing a nomogram, it was found that the area under the curve was 0.753 (95% CI=0.686-0.818), and the best cutoff value obtained by Youden index was 0.164. Moreover, the calibration curve indicated the best consistency between the predicted probability and the actual probability.Conclusion: We developed a nomogram, which was novel and accurate, to predict the risk of ICC in patients received biliary surgery for biliary calculi. This nomogram is of certain significance for the early detection of ICC.

Use of a Fogarty Balloon Catheter to Create Backwall Support and Facilitate Intrahepatic Bile Duct Access During Antegrade Stone Extraction

Percutaneous transhepatic stone removal may be indicated in patients with altered upper gastrointestinal anatomy precluding use of endoscopic stone extraction. When biliary calculi are located in a duct adjacent to the duct cannulated percutaneously, obtaining wire and catheter access into the target duct may be difficult due to the acute angles required of the wire and catheter to access the stone-containing duct. One useful method described and illustrated in this chapter to address this issue involves inflating a balloon catheter downstream from the origin of the target duct to deflect a wire into the target duct and to provide backwall support at the apex of the wire for advancement of the stiff balloon catheter. Once the duct containing the biliary calculi is accessed, sweeps of the calculi can be performed.

Clinicopathological study and management of biliary stones

Background: Biliary calculi are one of the most common problems affecting the digestive tract. Need for the study is to evaluate age, sex, incidence, most common etiopathological factors for the formation of biliary calculi and to illustrate varying clinical presentation with various modes of management adopted in the institution as well as to analyse biochemical types of stones prevalent in the region.Methods: A prospective study of 50 patients with clinical diagnosis of biliary colic was conducted in a tertiary center for a period of one year. Clinical presentation, etiology, and management of biliary calculi were studied.Results: Biliary calculi affect most commonly in fourth to the fifth decade with a higher preponderance in females (72%). Right hypochondriac pain is the commonest presentation (84%). Ultrasonography is sensitive and specific, and hence considered the investigation of choice. Open surgical procedures such as cholecystectomy, choledochotomy with T-tube drainage, choledochoduodenostomy were done in these subjects. Postoperative complications such as wound infection noted in 8% of the subjects. Most of the histopathological specimens (90%) revealed chronic cholecystitis.Conclusions: Biliary calculus disease is multifactorial in origin with slight female preponderance. The most common presentation is a right hypochondriac pain. This can be diagnosed accurately with the aid of ultrasonography and Endoscopic Retrograde Cholangio-pancreatography. Biliary calculus is managed according to the location of the calculus, whether intrahepatic or extrahepatic. Most of the patients presented with chronic cholecystitis.