November 3 2018 Aleysia Kroptavich Overview of presentation Description of disease Case report General information Medical history Surgical history Social history Nutritional history Case discussion ID: 760856
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Slide1
Gallstone ileus
DI Clinical Case Study
November 3, 2018
Aleysia Kroptavich
Slide2Overview of presentation
Description of disease
Case report
General information
Medical history
Surgical history
Social history
Nutritional history
Case discussion
References
Slide3Gallstone ileus
Gallstone ileus is an uncommon cause of a mechanical small bowel obstruction. It is a rare complication of chronic cholecystitis and occurs when a gallstone passes through a fistula between the gallbladder and small bowel before becoming impacted at the ileocecal valve. HistoryThe first descriptions of gallstone ileus occurred in 1654 by Thomas Bartholin (1616-1680), a Danish physician, naturalist, physiologist, and anatomist.
Incidence- Although overall gallstone ileus is an uncommon cause of small bowel obstruction (1-4% in general adult population 9), in the elderly is not uncommon, and accounts for up to 25% of non-strangulated bowel obstructions. As is the case with cholelithiasis, women are more frequently affected.
Etiology
Gallstone ileus is a mechanical intestinal obstruction due to gallstone impaction within the gastrointestinal tract. Less than 1% of cases of intestinal obstruction are derived from this etiology.
Symptoms- The symptoms and signs of gallstone ileus are mostly nonspecific with intermittent symptoms of nausea, vomiting, abdominal distension, and pain.
Prognosis
-
Because the condition tends to affect the old and frail, there is a 20% mortality. There appears to be no real difference in terms of the operative procedure performed -
eg
, simple
enterolithotomy
to fistula repair.
Slide4Gallstone ileus: treatments
Surgical TreatmentRemoval of the obstruction at laparotomy should be accompanied by a careful search for other gallstones proximal to the obstruction.The one-stage procedure should be reserved for stabilized patients. In cases with significant associated comorbidities, enterolithotomy alone may represent the best option.A laparoscopic technique has been shown to be effective for some patients with gallstone ileus.
Dietary Treatment
A patient with gallstone ileus should not eat until it is resolved.
Proper nutrition is important to prevent malnutrition and weight loss, as well as supply necessary nutrients for healing. This is accomplished by nutrition support.
If infection is the cause, an antibiotic is prescribed.
Medications can be given to stimulate peristalsis, according to the National Institutes of Health.
Slide5admission
“The patient:
“L.L”
, a 62 year old Caucasian female.
Admitted with profuse vomiting, weakness and abdominal pain
Decreased PO intake x 5 days
Decreased urination
Last reported bowel movement: October 25, 2018
Total hospital stays = 8 days
Slide6Medical history
L.L.’s medical history includes the following:
Colon polyp – cancerous
OSA (Obstructive Sleep Apnea) w/ CPAP use
COPD (Chronic Obstructive Pulmonary Disease)
Arrhythmia
Gallstone Ileus
GERD
Small bowel obstruction
Slide7Surgical history
L.L. has had the following surgeries:
Removal of a cancerous colon polyp
Laparotomy for hernia repair
Slide8Social history
L.L. is currently married and living at home with her husband.
No children
Independent and active functional status
Denies drug use, alcohol use and tobacco use
Former smoker: quit Jan. 1, 2007
Slide9Nutritional history
L.L. reported her baseline nutritional intake as:
3 meals/day
Followed a regular diet
No food allergies
One week prior to ER visit:
Minimal PO intake consumption of foods or liquids due to crampy intermittent abdominal pain and vomiting profusely.
No weight loss reported
Current weight:
268 lbs.
IBW
: 130 lbs.
BMI: 36.3 kg/m^2 :
obese class
Height: 72 inches
Slide10Current medications
L.L. was admitted with the following medications:
Slide11assessment on admission
L.L. was admitted to the ER on October 29, 2018
Post ER admittance:
CT of the abdomen and pelvis was performed as well as a single organ ultrasound:
Moderate hiatal hernia
Severe fatty liver
Low-density nodular thickening of both adrenal glands consistent with small bilateral adrenal adenomas
Gallbladder present, but completely contracted; no wall thickening
Small amount of gas in the lumen of the gallbladder as well as slight
pneumobilia
Pancreas not seen due to overlying bowel gas
Moderately dilated small bowel loops whereas the distal ileal loops are decompressed
Bladder empty
Liver demonstrated increased echogenicity
Common bile duct measured 0.7 cm and the right kidney measured 10.0 cm in length
Slide12Impression on admission
L.L. appeared to have a mid small bowel obstruction related to a 2.4 cm gallstone (aka gallstone ileus), a systolic murmur suggesting aortic stenosis and a history of some undisclosed arrhythmia.
NPO diet with a NGT and a Foley
Placed in the ICU for resuscitation
Undergo a laparotomy
Antibiotics and
protonix
given
Slide13Medical treatment
L.L. was intubated and the following procedures were performed:
Laparotomy
- any surgical incision into the abdominal wall, usually performed under general or regional anesthesia, often on an exploratory basis. Food and fluids by mouth are withheld for several hours before surgery.
NG Tube and Foley placement
Medications at this time:
Cetirizine Hydrochloride (10 mg/d), S Omeprazole (40 mg/d),
Dulera
inhaler (1 puff/d), Montelukast (10 mg/d) and Spiriva inhaler (2x/d).
Slide14Medical treatment
Day 2:
Diet: NPO
Calcium 11.0 on admission, indicating hypercalcemia
Abdomen soft, distended and showed some mild periumbilical tenderness
An echocardiogram was done and showed sinus rhythm and minor nonspecific ST-T abnormality
Murmurs drained in both carotids of the neck and 2-3/6 systolic ejection murmur at the left sternal border that radiates toward the apex
Diagnoses at this time:
Gallstone Ileus, Hypercalcemia, AKI, Leukocytosis, GERD, a heart murmur and Arrhythmia
Slide15Medical treatment
Day 3:
L.L. still NPO, on NGT 700 cc
Urine output improved, so Foley removed
Lab closely monitored:
Calcium: 8.4 after IV fluid
Slide16Medical treatment
Day 4:
L.L. progressing slowly:
abdomen still soft and still mildly distended
Dressing cleaned
NGT discharged; Pt remained NPO with IV fluids
Hypercalcemia resolved
No bowel movement, but passed flatus
Pain well controlled
No chest pain or SOB
Lungs appeared clear
Regular rate and heart rhythm as well as systolic murmur
Positive bowel sounds
% Meals consumed with clear liquid diet : 100%
Slide17Medical treatment
Day 5:
L.L. felt well and exam came back good!
passed some flatus and was ambulating
Tolerated clear liquids
a
dvanced to full liquids
% meals consumed:
100%
at 08:38 and 09:52
50%
at 15:17
10%
at 18:42
Slide18Medical treatment
Day 6:
One episode of vomiting and felt shortness of breath (SOB)
Had a small bowel movement and flatus
% meals consumed:
50%
at 08:58
100%
at 13:24
10%
at 18:18
PES statement:
Altered gastrointestinal function (NC-1.4) related to a short bowel obstruction associated with a 2.4 cm gallstone as evidenced by patient complaints of abdominal pain and vomiting.
Slide19Nutritional therapy
Nutritional Recommendations:
Encourage smaller, more frequent meals and drink plenty of fluids throughout the day to resolve COPD symptoms.
Encourage a healthy diet, weight loss and physical activity to prevent gallstones from reoccurring
Nutritional Goals:
Achieve normal bowel function
Nutrition Interventions:
Diet advancement to regular diet
Slide20Medical treatment
Day 7:
Afebrile VSS Exam = good!
Diet advanced to a regular diet
Kcals:
1500 kcals/d
Protein:
60 g/d
COPD diet teaching provided
smaller, more frequent meals
Consist amount of fluid intake throughout the day
Gallstone Ileus prevention:
diet recommendations provided
Balanced mix of plant-based foods
Gradual weight loss
Regular exercise ~30 min/d
Slide21Discharge
Discharged to home on the even of 11/4 with husband
Over the course of her stay at WMH:
Taken to OR to have a laparotomy with removal and repair of gallstone from small bowel
Had a large amount of inflammation in her RUQ; resolved
Remained on antibiotics for 5 days, post-operatively
She slowly improved with the multiple different diets she was put on and was able to be advanced to a regular diet
Slide22labs
NameResultSodium145 mmol/LPotassium3.7 mmol/LChloride111 H mmol/LCarbon Dioxide28.0 mmol/LBUN17 mg/dLCreatinine0.81 mg/dLEst GFR (Non-Af Amer)>60.0 ml/min
Glucose
85 mg/dL
Lactic Acid
1.4 units/L
Calcium
8.9 mg/dL
Total Bilirubin
0.66 mg/dL
Slide23Labs (continued)
Name: Result:AST22 unit/LALT37 unit/LAlkaline Phosphatase106 unit/LTroponin I<0.02 ng/mLTotal Protein6.0 L g/dLAlbumin2.7 L g/dLAmylase17 L units/L
Lipase
150 unit/L
Procalcitonin
0.2 ug/L
Slide24Research #1
2011 study by
Davidovic
,
Tomic
and
Jorg
.
Found that individuals with an energy intake higher than their energy expenditure were 15.7 times more likely to develop gallstones.
The study assessed the nutrition of 55 patients with gallstones and 59 patients without by performing 24-hour recalls.
In men and women with gallstones, the mean energy intake was found to be 15.54% and 16.18% higher than those without gallstones. Gallstone patients were also found to have higher fat intake by 24.3% and 60% had no food intake for 12 hours or longer compared to 25% in the healthy group.
This data suggests eating an appropriate amount of calories and a low-fat diet can help reduce the risk of gallstone disease.
Citation
:
Davidovic
, D. B.,
Tomic
, D. V.,
Jorg
, J. B. (2011). Dietary habits as a risk factor of gallstone disease in Serbia. Acta
Chir
Iugosl
. 58(4), 414.
Slide25Research #2
2017 study by Hangzhou.
Determined that asymptomatic gallstones are strongly associated with NAFLD in the Chinese study population.
This was determined by enrolling those out of 7,583 subjects in the study that completed a questionnaire and underwent a medical and ultrasound exam between 2009 and 2011.
Data was gathered by using colorimetric methods to measure the levels of cholesterol, high-density lipoprotein cholesterol (HDL-C) and low-density lipoprotein cholesterol (LDL-C) and a dextrose-oxidizing enzyme method was used to measure fasting plasma glucose (FPG).
Patients with asymptomatic gallstones had a higher prevalence of NAFLD than in those without asymptomatic gallstones (58.98% vs 46.58%).
Citation
: Zhejiang, H. Nonalcoholic fatty liver was associated with asymptomatic gallstones in a Chinese population. 96(38);2017 Sept. [PMC free article] [PubMed]
Slide26Laparoscopic Enterolithotomy for Gallstone Ileus
https://www.youtube.com/watch?v=o6CYizm31JQ
Slide27summary
Although it’s rare, gallstone ileus should be kept in mind when dealing with small bowel obstructions, especially in elderly patients in whom the diagnosis is often ignored. Most small bowel obstructions are easily treated if caught early. Early surgical intervention is the mainstay of treatment, a laparotomy being the most valid surgical approach. My case study patient had a successful laparotomy and was discharged on a regular diet and with the knowledge that she needed to adequately feed and hydrate herself with COPD and to prevent gallstones from reoccurring.
Slide28bibliography
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Slide29bibliography
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Davidovic
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Tomic
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Jorg
, J. B. (2011). Dietary habits as a risk factor of gallstone disease in Serbia. Acta
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15. Phillips S. Diet After Small Bowel Obstruction. LIVESTRONG.COM. Published August 14, 2017. Accessed November 16, 2018