Cramplike Pain and Vomiting in a 77-Year-Old Man

James J. McCombie, MB ChB; Erik D. Schraga, MD

Disclosures

March 28, 2017

Discussion

This patient had mechanical small-bowel obstruction complicated by perforation and subsequent peritonitis. His history and examination findings were consistent with this sequence of events. Loss of liver dullness on right upper quadrant abdominal percussion is known as Jobert’s sign and is considered a pathognomonic sign of large visceral perforation. Further support for this was found on the erect chest and supine abdominal radiographs; a large amount of free intraperitoneal air and dilated loops of small bowel were noted. Some authors refer to this radiological finding as Chilaiditi's sign, although the original description by the radiologist Dimitrius Chilaiditi in 1910 described it, not as free air over the liver, but rather the overlapping of a segment of intestine (usually the hepatic flexure of the colon) between the liver and the right diaphragm. Regardless of the underlying etiology, the initial treatment for intra-abdominal free air with peritonitis is emergency laparotomy.

After resuscitation, the patient was transferred to the operating room for exploratory laparotomy. During the procedure, it was revealed that the peritoneal cavity was grossly contaminated with intestinal contents spilling out from a small orifice in the terminal ileum. The cause of the obstruction was found to be a gallstone 1.18 in in diameter that was impacted at the ileo-cecal valve. The gallbladder was adherent to the duodenum. The entire length of the bowel was examined for other stones, but none were found.

The stone was gently massaged in order to move it proximally, and it was removed via enterolithotomy. The perforation was closed with interrupted sutures and, after copious lavage, the abdomen was closed.

Cholelithiasis is a common disorder prevalent in 10% of the population, with symptomatic manifestation in 20%-30% of those affected.[1,2] Gallstone disease may present with an assortment of complications that are usually the result of stones within the gallbladder and biliary tree, with the most common presentation being biliary colic. Extrabiliary problems are rare; however, some 3%-5% of patients with cholelithiasis have a cholecystoenteric fistula as part of the spectrum of their disease, most commonly occurring between the gallbladder and duodenum (71.4%), followed by a fistula with the stomach (14.3%) or the colon (6.3%).[3]

In addition, fistulae may arise between the common bile duct and the intestinal tract, and other organs and the abdominal wall, have also been reported as being involved. The possibility of concurrent Mirizzi syndrome (a rare condition in which gallstones lodged in the Hartmann pouch or cystic duct externally compress the common hepatic duct or even erode into the common bile duct or bowel) should be ruled out, because an association between these has been suggested.

Gallstones may migrate into the gastrointestinal tract through such a fistula (as in the case of this patient), but most cases pass without incident. Stones larger than 0.7-1.0 in, however, are at risk of becoming impacted.[4] Gallstones can grow in diameter as they pass through the intestinal lumen and sediment from the bowel contents is deposited onto them.

In a series of 40 patients, the site of impaction was found to be the ileum in 25 patients, jejunum in nine, duodenum in three, and colon in one.[5] A further review of 1001 patient cases delineated these sites further, with the terminal ileum and ileocecal valve reportedly being most commonly involved, followed by the ligament of Treitz and the pylorus; the duodenum and sigmoid colon were relatively rare locations for impaction of a gallstone within the enteric tract.[6] These sites represent regions of anatomically smaller luminal diameter. Colonic obstruction would probably occur only if preexisting pathology, such as a colonic stricture, were present.

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