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Zorluk: OrtaGastrointestinal and Abdominal Surgery

A surgical consultation is requested for an 82-year-old female patient admitted earlier today with intractable vomiting and severe abdominal distension. The patient resides in an assisted living facility and has a past medical history significant for atrial fibrillation, type 2 diabetes mellitus, and symptomatic cholelithiasis for which she previously declined operative intervention. Over the past two hours, her abdominal pain has become sharp and constant. Vital signs show a temperature of 38.3°C (100.9°F), pulse of 118/min, and blood pressure of 96/60 mm Hg. Physical examination reveals a markedly distended, tympanic abdomen with focal tenderness and involuntary guarding in the right lower quadrant. Laboratory testing demonstrates a leukocyte count of 15,200/mm³ and a mild non-anion gap metabolic acidosis. A non-contrast computed tomography scan of the abdomen shows branching radiolucencies in the liver, prominent dilation of the jejunum and proximal ileum, and a 3.5-cm radiopaque structure impacted just proximal to the ileocecal valve. Which of the following is the most appropriate next step in the management of this patient?

  1. Exploratory laparotomy with enterolithotomy aloneCevap
  2. B
    Nasogastric tube placement and serial abdominal examinations
  3. C
    Exploratory laparotomy with enterolithotomy, cholecystectomy, and fistula repair
  4. D
    Enteral administration of a water-soluble contrast agent
  5. E
    Endoscopic retrograde cholangiopancreatography with stone extraction

Cevap

Exploratory laparotomy with enterolithotomy alone
The correct answer is exploratory laparotomy with enterolithotomy alone. The patient's clinical presentation and imaging findings are highly characteristic of gallstone ileus, a mechanical small bowel obstruction caused by a large gallstone that has eroded through the gallbladder wall into the adjacent gastrointestinal tract. The classic imaging findings constitute Rigler triad: pneumobilia, small bowel obstruction, and an ectopic radiopaque gallstone. This patient also demonstrates signs of bowel ischemia or impending perforation, including fever, tachycardia, focal tenderness, involuntary guarding, and leukocytosis. The definitive management for gallstone ileus is surgical relief of the obstruction. In an elderly and hemodynamically unstable patient, the safest and most appropriate approach is an exploratory laparotomy with enterolithotomy (an incision in the bowel to extract the stone) alone. Addressing the cholecystoenteric fistula and removing the gallbladder concurrently is associated with a very high mortality rate in frail patients.

Adım Adım Çözüm

1
Identify the primary diagnosis based on the clinical vignette and imaging findings.
The patient has gallstone ileus, confirmed by the presence of Rigler triad (pneumobilia, small bowel obstruction, and an ectopic gallstone in the terminal ileum).
The large gallstone eroded through the gallbladder wall into the intestine, creating a cholecystoenteric fistula, and impacted at the narrowest point of the bowel.
2
Assess the patient's clinical status to determine the urgency of intervention.
The patient is hemodynamically unstable (hypotension, tachycardia) with signs of peritonitis (fever, guarding, leukocytosis).
These findings suggest impending or established bowel ischemia, which turns the mechanical obstruction into a surgical emergency.
3
Select the most appropriate definitive treatment for this specific patient population.
Exploratory laparotomy with enterolithotomy alone is selected.
In elderly, frail, or hemodynamically unstable patients, the safest operative approach is the simplest one that resolves the acute life-threatening obstruction. Addressing the fistula and performing a cholecystectomy concurrently (a one-stage procedure) carries excessive morbidity and mortality.

Anahtar Kavram

Diagnosis and surgical management of gallstone ileus in unstable or elderly patients.
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Konular

Gastrointestinal and Abdominal Surgery

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