Browning Louise E, Taylor Jeremy D, Clark Sue K, Karanjia Nariman D
Department of Surgery, University Hospital Lewisham, Lewisham, UK.
J Med Case Rep. 2007 Nov 28;1:157. doi: 10.1186/1752-1947-1-157.
Gallstone ileus is an uncommon complication of cholelithiasis but an established cause of mechanical bowel obstruction in the elderly. Perforation of the small intestine proximal to the obstructing gallstone is rare, and only a handful of cases have been reported. We present two cases of perforation of the jejunum in gallstone ileus, and remarkably in one case, the gallstone ileus caused perforation of a jejunal diverticulum and is to the best of our knowledge the first such case to be described.
Case 1A 69 year old man presented with two days of vomiting and central abdominal pain. He underwent laparotomy for small bowel obstruction and was found to have a gallstone obstructing the mid-ileum. There was a 2 mm perforation in the anti-mesenteric border of the dilated proximal jejunum. The gallstone was removed and the perforated segment of jejunum was resected.Case 2A 68 year old man presented with a four day history of vomiting and central abdominal pain. Chest and abdominal radiography were unremarkable however a subsequent CT scan of the abdomen showed aerobilia. At laparotomy his distal ileum was found to be obstructed by an impacted gallstone and there was a perforated diverticulum on the mesenteric surface of the mid-jejunum. An enterolithotomy and resection of the perforated small bowel was performed.
Gallstone ileus remains a diagnostic challenge despite advances in imaging techniques, and pre-operative diagnosis is often delayed. Partly due to the elderly population it affects, gallstone ileus continues to have both high morbidity and mortality rates. On reviewing the literature, the most appropriate surgical intervention remains unclear.Jejunal perforation in gallstone ileus is extremely rare. The cases described illustrate two quite different causes of perforation complicating gallstone ileus. In the first case, perforation was probably due to pressure necrosis caused by the gallstone. The second case was complicated by the presence of a perforated jejunal diverticulum, which was likely to have been secondary to the increased intra-luminal pressure proximal to the obstructing gallstone.These cases should raise awareness of the complications associated with both gallstone ileus, and small bowel diverticula.
胆石性肠梗阻是胆石症一种罕见的并发症，但却是老年人机械性肠梗阻的既定病因。梗阻性胆石近端的小肠穿孔罕见，仅有少数病例报道。我们报告两例胆石性肠梗阻患者空肠穿孔的病例，值得注意的是，其中一例胆石性肠梗阻导致空肠憩室穿孔，据我们所知这是首例此类病例。
病例1 一名69岁男性，出现两天呕吐及中腹部疼痛症状。因小肠梗阻接受剖腹手术，发现一枚胆石阻塞回肠中部。扩张的近端空肠对系膜缘有一个2毫米的穿孔。取出胆石并切除穿孔的空肠段。病例2 一名68岁男性，有四天呕吐及中腹部疼痛病史。胸部和腹部X线检查无异常，但随后的腹部CT扫描显示有气腹。剖腹手术时发现其远端回肠被一枚嵌顿的胆石阻塞，空肠中部系膜表面有一个穿孔的憩室。进行了肠石切除术及穿孔小肠切除术。
尽管影像技术有所进步，但胆石性肠梗阻仍是一个诊断难题，术前诊断往往延迟。部分由于其影响的老年人群，胆石性肠梗阻的发病率和死亡率仍然很高。查阅文献发现，最合适的手术干预措施仍不明确。胆石性肠梗阻中的空肠穿孔极其罕见。所描述的病例说明了胆石性肠梗阻并发穿孔的两种截然不同的病因。在第一例中，穿孔可能是胆石引起的压力性坏死所致。第二例因存在穿孔的空肠憩室而复杂化，这可能是由于梗阻性胆石近端肠腔内压力增加继发的。这些病例应提高对胆石性肠梗阻及小肠憩室相关并发症的认识。
