Rosen & Barkin's 5-Minute Emergency Medicine Consult (287 page)

Hypothermia

CODES

• 991.0 Frostbite of face
  
• 991.1 Frostbite of hand
  
• 991.3 Frostbite of other and unspecified sites
  

BASICS

• Mechanical intestinal obstruction secondary to impaction of a gallstone within bowel lumen
  
• Stone is usually >2.5 cm
  
• 1–3% of all intestinal obstructions
  
• Most cases occur in patients >65
  
• Female > male (5:1)
  
• Mortality 15–18%
  

• Chronic gallbladder inflammation causes adhesions between gallbladder and adjacent bowel wall
  
• Cholecystocolonic fistula develops, permitting stone passage into intestine:
  
  • Duodenum is the most common site of fistula formation, followed by colon
    
  • Gastric fistulas are possible but rare
    
• Site of impaction
  
  • Terminal ileum most common (54–65%)
    
    • Narrowest part of small intestine at level of ileocecal valve
      
  • Jejunum (27%)
    
  • Duodenum (1–3%)
    
    • Gastric outlet obstruction caused by duodenal impaction referred to as
      Bouveret syndrome
      
  • Large bowel obstruction is rare
    

DIAGNOSIS

• “Tumbling” abdominal discomfort:
  
  • Episodic abdominal pain as stone lodges and dislodges throughout the intestines.
    
  • Complete impaction leads to severe, often acute abdominal pain.
    
• Nausea
  
• Vomiting:
  
  • Can be bilious or feculent
    
• Obstipation
  
• Abdominal distention and tympany
  
• Abdominal tenderness:
  
  • Peritoneal findings develop late in the course of disease
    
• Abnormal bowel sounds
  

• Only 50–60% of patients have a history of biliary colic or gallstone disease.
  
• Gallstone ileus has been associated with cardiovascular disease, diabetes, and obesity.
  

• Abdominal exam for:
  
  • Abdominal distension/tenderness
    
• Jaundice may occur
  

Evaluate for intestinal obstruction.

• Electrolytes, BUN/creatinine, glucose since decreased oral intake and vomiting leads to electrolyte abnormality
  
• Liver function panel and bilirubin may be elevated
  
• Amylase:
  
  • Elevated in late obstructions
    
• CBC/hematocrit:
  
  • Hemoconcentration secondary to dehydration
    
• Elevated WBC nonspecific
  

• Flat and upright abdominal radiographs:
  
  • Multiple air–fluid levels and distended bowel consistent with bowel obstruction
    
  • Rigler triad: 2 of 3 pathognomonic (present in 30–50%):
    
    • Air in the biliary tree (pneumobilia)
      
    • Partial or complete bowel obstruction
      
    • Ectopic stone visualized within the intestinal tract
      
• CXR:
  
  • Evaluate for pneumoperitoneum
    
• Abdominal CT scan:
  
  • Test of choice
    
  • Can directly visualize and localize stone within intestinal lumen
    
• Abdominal US:
  
  • Can identify pneumobilia and gallstones, but lower yield in locating obstructing stone
    

• Paralytic ileus
  
• Extrinsic bowel obstruction:
  
  • Adhesions
    
  • Volvulus
    
  • Hernia
    
  • Intussusception
    
• GI malignancy
  
• Diverticulitis
  
• Bezoar
  
• Inflammatory bowel disease
  
• Pseudo-obstruction
  
• Cholecystitis
  
• Ascending cholangitis
  
• Pancreatitis
  

TREATMENT

Establish IV access

IV fluid resuscitation

• Nasogastric suction to decompress the stomach and intestine
  
• Nothing PO
  
• Electrolyte replacement
  
• Monitor urine output
  
• Analgesics
  
• Broad-spectrum antibiotics to cover bowel flora:
  
  • Piperacillin/tazobactam
    
  • Ampicillin/sulbactam
    
  • Ticarcillin/clavulanate
    
  • Alternatives include imipenem, meropenem, 3rd-generation cephalosporin + metronidazole.
    
• Surgical consultation
  

• Ampicillin/sulbactam: 3 g IV q6h (peds: 100–200 mg/kg/24 h)
  
• Piperacillin/tazobactam: 3.375 g IV q6h (peds: 240–400 mg/kg/24 h)
  
• Ticarcillin/clavulanate: 3.1 g IV q4–6h
  

FOLLOW-UP

• Admit all patients with gallstone ileus
  
• Surgical evaluation for emergent operative intervention
  

None

Surgical consultation in ED for evaluation and operative intervention

• Gallstone ileus is a mechanical intestinal obstruction rather than a true ileus.
  
• Emergent surgical consultation is required for definitive management.
  
• High mortality rates stem from delay in diagnosis and patient comorbidities.
  
• Suspect gallstone ileus in elderly patients, especially women, with signs/symptoms of bowel obstruction and no previous surgical history.
  
• Only 10% of ectopic gallstones can be visualized on plain radiographs. CT imaging is more sensitive and specific for detecting intraluminal stones.
  
• Only 1/2 of the patients have a previous history of biliary colic or gallstone disease.
  

• Bennett GL, Balthazar EJ. Ultrasound and CT evaluation of emergent gallbladder pathology.
  Radiol Clin North Am
  . 2003;41:1203–1216.
  
• Chou JW, Hsu CH, Liao KF, et al. Gallstone ileus: Report of two cases and review of the literature.
  World J Gastroenterol
  . 2007;13:1295–1298.
  
• Lobo DN, Jobling JC, Balfour TW. Gallstone ileus: Diagnostic pitfalls and therapeutic successes.
  J Clin Gastroenterol
  . 2000;30(1):72–76.
  
• Rosenberg M, Parsiak K. Vomiting gravel.
  Am J Emerg Med
  . 2004;22(2):131–132.
  
• Zaliekas J, Munson JL. Complications of gallstones: The Mirizzi syndrome, gallstone ileus, gallstone pancreatitis, complications of “lost” gallstones.
  Surg Clin North Am
  . 2008;88:1345–1368.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Cholecystitis
  
• Cholelithiasis
  

CODES