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Lege Artis Medicinae

DECEMBER 20, 2004

[BOUVERET’S SYNDROME]

KESZTHELYI László, FÓGEL Kristóf, VADINSZKY Péter, SÁVOLT Ákos, PŐCZE Balázs, BALOGH István

[INTRODUCTION - Gallstone ileus is a rare disorder among elderly population. The gallstone coming through a bilioenteral fistula into the gastrointestinal tract is stuck into the duodenal lumen causing ileus in approximately 0,5% of all cases. The syndrome is named after Bouveret, the first describer. CASE REPORT - Author present the case of 72 year old female patient with known cholelithiasis. Investigations proved existing cholelithiasis causing the patient abdominal pain one year before admission but she gave no consent to surgical intervention. An emergency admission to our department occurred after four days of abdominal pain and vomiting. The clinical status of the patient and abdominal X-ray examination suggested stomach evacuation disturbance. Double contrast barium swallow test and gastroscopy proved bowel obstruction caused by a gallstone. During surgery gastrotomy and the removal of gallstone was carried out. There were no postoperative complications and the patient was discharged home. CONCLUSION - Cholelithiasis should be resolved at any chosen time well before complications may occur. The simultaneous appearance of stomach evacuation problems and cholelithiasis should draw attention to this rare disease.]

Hungarian Radiology

OCTOBER 20, 2006

[The role of ultrasonography and X-ray examinations in the diagnosis of gallstone ileus in preoperative stage]

FARKAS József, KÁNYA László, LUDVIG Zsuzsanna, BENDE Sándor

[INTRODUCTION - Gallstone ileus develops in elderly patients as a result of complication of cholelithiasis and causes 1-3% of mechanical ileus. Due to its variable presentation and in many cases insidious and intermittent symptoms it is difficult to establish the diagnosis which is often delayed. The mortality rate is high and early diagnosis is essential. The role of X-ray, abdominal ultrasound and recently CT has been emphasized. The role of imaging studies was evaluated in the preoperative diagnosis of gallstone ileus based on their surgically proven cases. PATIENTS AND METHODS - From 1st January 1988 to 30th June 2004 nineteen operations were performed on seventeen patients suffering from gallstone ileus. The average age of the patients was 74.2 years, male/female ratio was 4/13. Ultrasound examination was performed in all cases before the operation. Plane X-ray examination also was carried out except in two cases. CT study was not performed preoperatively. The calculi were removed through an enterotomy whole. In four cases gall bladder were also removed and the biliary fistula was closed. The disease was diagnosed on the basis of symptoms described by Rigler. If two signs from the three was present the diagnosis was established. RESULTS - 17 cases out of 19 mechanical ileus were diagnosed, in one case acute cholecystitis and in one incarcerated abdominal wall hernia was suspected before surgery. Small bowel obstruction was found in all cases (jejunum in six cases, ileum in 13). In five cases multiple calculi were seen in the bowels. Two patients had to undergo surgery twice because of gallstone ileus. It is noted that in eight cases (42.1% of total operations) gallstone ileus was diagnosed before the operation. In seven cases ultrasound played a crucial role in establishing diagnosis. In one case gas was detected in the biliary tract and in six, gallstone was directly seen in the small bowel with ultrasound. CONCLUSIONS - In the preoperative diagnosis of gallstone ileus more and more is expected from appropriate radiological examinations. If diagnosis is primarily based on the physical examination, an illusion of clinical improvement can be created, and the delay of surgical treatment can lead to decompensation of elderly patients with increased mortality rate. A thorough radiological examination can show the stone in the bowel lumen, and observation of the indirect signs together with clinical state can considerably improve the results. The rate of correct diagnosis of gallstone ileus before sugery in our patients can be considered an average and similar to the published data in medical literature.]

Hungarian Radiology

OCTOBER 20, 2006

[Successful radiological diagnostics in Bouveret’s syndrome]

KISS Katalin, FARKAS Szabolcs, LUKOVICH Péter, MAGYAR Péter, MESTER Ádám, MAKÓ Ernő

[INTRODUCTION - Bouveret’s syndrome I is a rare clinical entity, a special form of gallstone ileus. Based on a case study the authors describe the clinical presentation, the complications and diagnostic work up of the Bouveret’s syndrome I. CASE REPORT - A 75-year-old female patient with repeated vomiting and haematemesis was examined. Known gallstones and obstructive jaundice was noted in the case history. Urgent gastroscopy was performed at admission, which proved haemorrhagic esophagitis as the cause of the haematemesis. A gallstone was found by endoscopy distal to the pyloric region obstructing the bowel lumen. Radiological examinations proved the presence of the stone exactly at the localization that was given. Surgery confirmed the diagnosis. CONCLUSION - Bouveret’s syndrome I should be considered in patients with repeated and long lasting vomiting and bile stone in the case history. Conventional X-ray may be sufficient to establish the diagnosis, however further imaging studies are needed to clarify exact anatomical situation and potential complications of the disease.]