ACUTE ABDOMEN IN AN ELDERLY PATIENT

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ACUTE ABDOMEN IN AN ELDERLY PATIENT:

ACUTE ABDOMEN IN AN ELDERLY PATIENT DR. BIGGS SARAVANAN R , DEPARTMENTS OF MEDICAL AND SURGICAL GASTROENTEROLOGY, MADRAS MEDICAL COLLEGE.

Hx:

Hx 72 Y/O female Abd pain of 3 days/ Central abdomen/colicky Abd distention of 3 days Vomiting 2 days/ small quantity/ bilious / no blood

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Not passing stools and flatus for 2 days No h/o urinary abnormalities No fever /cough No h/o fall/ trauma BOX before this episode was normal

Past Hx:

Past Hx Not a known DM,HTN,COPD,TB, CAD,TIA B/L Total Hip Replacement 7 years ago No abd Surgery No Hx any prior abdominal pain. Other Hx non contributory

O/E:

O/E Elderly frail lady Conscious/oriented No pallor, cyanosis, clubbing P/A Distended/ slightly tender/ not warm Resonant B/S –decreased P/R- NAD

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?

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Intestinal obstruction

Abd X ray Erect:

Abd X ray Erect

USG Abd:

USG Abd Apart from the dilated small bowel loops no significant findings LABS CBC- WNL LFT- WNL RFT-WNL

Axial CT-Abd:

Axial CT- Abd

Coronal CT:

Coronal CT

Coronal CT:

Coronal CT RIGLER’s Triad (Rigler et al 1941) Pneumobilia Dilated small intestinal loops Ectopic gall stone

Final Diagnosis:

Final Diagnosis Small intestinal obstruction due to gall stone ( Gall stone ileus)

Tx options:

Tx options Surgical Endoscopic

Tx- Entero lithotomy:

Tx - Entero lithotomy

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Patient is doing fine post operatively. Planning for second surgery- cholecystectomy with fistula repair.

REVIEW OF LITERATURE:

REVIEW OF LITERATURE “Gallstone ileus” is a misnomer- true mechanical obstruction . Gallstone ileus is an unusual cause of intestinal obstruction. 1% to 4% of all cases . In the seventh or eighth decades of life

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Stone can enter the bowel thru duodenum, hepatic flexure, stomach in descending order of frequency. Site of obstruction ileum(60%) Jejunum (15%), stomach (15%), colon (5%).

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Diagnosis is delayed in up to half of the patients . Nonspecific and inconsistent symptoms. Only 50% to 70% of patients have clinical features of SBO. The classic radiologic features of gallstone ileus - pneumobilia , intestinal obstruction, aberrant gallstone location, and a change in the location of a previously observed stone.( Rigler’s triad)

X-ray abd RIGLERS TRIAD CEC T-Abd:

X-ray abd RIGLERS TRIAD CEC T- Abd

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10% of gallstones are sufficiently calcified to be identified on plain x ray abd. Pneumobilia and the biliary-enteric fistula were identified in nearly 90% and 12% of surgically proven cases, respectively. (Lassandro F,  et al: Role of helical CT in diagnosis of gallstone ileus and related conditions.   Am J Radiol   2005; 185:1159-65.)

Rx:

Rx Operative enterolithotomy . Endoscopic removal of the stone with or without lithotripsy. ( few case reports available). ( Hauke et al. World J Gastrointest Endosc 2010 September 16; 2(9): 321-324) (L ubbers et al . J Intern Med 1999; 246: 593±597.)

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Enterolithotomy alone is the appropriate initial treatment . (the emergent nature of this procedure, the advanced age , and the presence of a complex RUQ mass containing the cholecystoenteric fistula ).

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Elective cholecystectomy with repair of the fistula performed after recovery. 17% of patients develop recurrent gallstone ileus or other biliary complications after enterolithotomy alone. (Reisner RM, Cohen JR: Gallstone ileus: a review of 1001 reported cases.   Am Surg   1994; 60:441-6).

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11 elderly patients treated with enterolithotomy alone didn’t develop biliary symptoms on 4 years of follow-up. (Lobo DL, Jobling JC, Balfour TW: Gallstone ileus: diagnostic pitfalls and therapeutic successes.   J Clin Gastroent   2000; 30:72-6).

Bouveret syndrome:

Bouveret syndrome Gall stone in duodenum causing GOO Rx is similar

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THANK YOU

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