Overview of Gallstone Intestinal Obstruction
Gallstone intestinal obstruction is an intestinal obstruction caused by the entry of gallstones into the intestinal tract, causing intestinal obstruction. The onset of the disease is insidious, with intermittent episodes at the beginning of the disease course, and not every patient has a typical presentation on X-ray, and the diagnosis is obtained preoperatively in only 10% to 75% of the patients. The disease was first reported by Bartholin in 1654. It is clinically rare and is more common in females, with a male to female ratio of 1:3 to 1:16.
Causes
The cause of gallstone intestinal obstruction is the entry of huge gallstones into the intestinal tract, and the diameter of the stones that can cause intestinal blockage and obstruction is usually more than 2.5cm, and Turner reported that the diameter of one case of gallstone was 17.7cm.
1.There is an abnormal channel between bile duct and gastrointestinal tract.
This is the pathologic basis of gallstone intestinal obstruction, common abnormal channels between bile duct and gastrointestinal tract are: choledochoduodenal fistula, gallbladder-duodenal fistula, gallbladder-colon fistula, gallbladder-gastric fistula and choledochoduodenal fistula, etc, of which gallbladder-duodenal fistula accounted for about 3/4. hu guobin et al. admitted a case of hepatic and biliary stones, found that there was a huge internal fistula between the left hepatic duct and the stomach, which could pass through the fistula to enter into the gastric system. Stones can enter the intestine through the fistula.
2. Medical factors
The purpose of internal drainage is to re-establish smooth bile drainage, but in essence, it is equivalent to the artificial formation of biliary intestinal fistula, in order to facilitate the passage of stones. If the hepatic bile duct stones after the biliary and intestinal drainage. Hunan Provincial People’s Hospital has reported a case of gallstone intestinal obstruction after receiving hepatobiliary pelvic internal drainage.
Most of the gallstones causing obstruction are one to several. Gallstone obstruction can occur in any part of the intestine, but is most likely to occur at the end of the ileum. A large gallstone enters the proximal part of the intestinal lumen, and the plane of obstruction gradually decreases as the stone continues to descend. The stone may compress the intestinal wall, causing increased ischemia and exudation, and excessive fluid may accumulate in the proximal dilated intestinal collaterals. The intestinal wall becomes necrotic and perforated, and the intestinal contents leak out of the intestinal lumen into the peritoneal cavity, forming diffuse peritonitis.
Symptoms
Clinical manifestations are categorized as acute or chronic, high or low, partial or complete intestinal obstruction. In the early stage of the disease, partial obstruction, symptoms are mild, manifested as paroxysmal abdominal colic, accompanied by nausea, vomiting, this is the gallstone blocking the proximal intestinal canal with large internal lumen, stimulate the intestinal tract to produce strong intestinal peristalsis caused by the decline of the stone, the obstruction plane is reduced, the symptoms also change with the progression of the disease, such as anal stopping defecation, defecation, abdominal distension progressively aggravated, abdominal pain, abdominal pressure, plank abdomen, a small number of patients develop jaundice and Jaundice and gastrointestinal bleeding may occur in a few patients. Complications such as intestinal torsion, intestinal strangulation and intestinal perforation may occur in a few patients in the late stage of the disease.
Examination
Abdominal X-ray examination may have 4 features:
1. intestinal obstruction due to most of the stones are not big and smooth, in the intestine can gradually move down, so the obstruction is mostly incomplete, and the obstruction point changes, but the small intestine is low, the ileocecal valve mouth is often the obstruction point, the obstruction is mostly in the small intestine, and obstruction can also occur in the colon.
2. Gallbladder, bile duct accumulation of gas, to the bile duct accumulation of gas is more, can be a thick tube, there can also be small branches, due to obstruction before the bile duct obstruction, so the bile duct is thicker than normal, usually more than the sphincter of Oddi relaxation, biliary roundworms bring in the gas, or other reasons, and intestinal fistula, biliary – gastroenterological anastomosis caused by biliary duct accumulation of gas, appear more thick, to identify.
3. Intestinal gallstones, about 50% of gallstones can be visualized under X-ray, and some of them are fainter, so about half of gallstone intestinal obstruction only have the manifestation of intestinal obstruction and biliary tract pneumatosis, without gallstones.
4. Barium meal or barium enema examination, see barium into the biliary tract or directly lining the biliary tract of the stone shadow.
Diagnosis
1. Medical history
Elderly, obese female with a past history of cholelithiasis.
2. Clinical manifestations
Symptoms and signs of acute or chronic, high or low, partial or complete intestinal obstruction. Characteristic manifestations of this disease are: the symptoms are mild at the beginning of the disease, with the stone moving downward, the obstruction plane gradually decreases, and the symptoms and signs also change with the progress of the disease.
3.Auxiliary examination
X-ray examination has four signs: (1) partial or complete intestinal obstruction; (2) biliary gas; (3) ectopic, i.e., there is a gallstone shadow in the area outside the biliary system; (4) barium meal or barium enema examination, barium is seen to enter the bile ducts or lining the bile ducts with the shadow of the stone directly.
When complications occur, this disease is easily confused with intussusception and perforated peptic ulcer.
Treatment
Once the diagnosis is confirmed, surgery should be performed as early as possible in order to relieve the obstruction. There are several surgical methods:
1. Squeezing the obstructing stone into the colon;
2. Enterotomy to remove the stone;
3. cholecystectomy and internal fistula repair at the same time as enterotomy for stone removal. The entire gastrointestinal tract should be explored in detail intraoperatively.