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[JAMA临床挑战]:70岁女性患者出现腹痛及低血压(答案)
2023年11月21日 临床影像, 临床话题 [JAMA临床挑战]:70岁女性患者出现腹痛及低血压(答案)已关闭评论

Abdominal Pain and Hypotension in a 70-Year-Old Woman

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.

Case

A 70-year-old woman with hypertension, atrial fibrillation, congestive heart failure, and gallstones presented to the emergency department with 3 days of nausea, vomiting, and abdominal pain. She reported no hematemesis, hematochezia, or melena and had no history of abdominal surgery. On admission to the emergency department, she was afebrile, her blood pressure was 80/60 mm Hg, and heart rate was 122/min. On physical examination, her abdomen was distended, tympanic, and slightly tender to palpation diffusely. Blood testing showed a white blood cell count of 10 450/μL (84.1% neutrophils); C-reactive protein level, 9.5 mg/dL; potassium level, 3.0 mEq/L (reference, 3.6-5.2 mEq/L); and creatinine level, 5.57 mg/dL (429.39 μmol/L, up from a baseline level of 0.80 mg/dL [70.72 μmol/L]). Sodium and liver function values were normal.

In the emergency department, she received a 500-mL bolus of intravenous crystalloid fluid and 1 g of intravenous ceftriaxone. A nasogastric tube was placed and initially drained 300 mL of biliary fluid.

A non–contrast-enhanced abdominal computed tomography (CT) scan was performed (Figure 1).

Figure 1.

What Would You Do Next?

  1. Administer barium through the nasogastric tube to evaluate for bowel obstruction
  2. Order magnetic resonance cholangiopancreatography
  3. Perform an emergency explorative laparotomy
  4. Plan for surgical intervention after intravenous fluid resuscitation in the intensive care unit (ICU)

Discussion

Diagnosis

Gallstone ileus

What to Do Next

D. Plan for surgical intervention after intravenous fluid resuscitation in the intensive care unit (ICU)

The key to the correct diagnosis is recognition that the combination of an ectopic gallstone in the small bowel and a thickened gallbladder wall with intraluminal air adherent to the duodenum is characteristic of a cholecystoenteric fistula. Choice A is incorrect because administration of barium could worsen bowel obstruction and can induce barium peritonitis in the setting of bowel perforation.1 Ordering magnetic resonance cholangiopancreatography (choice B) is not recommended because the abdominal CT scan findings confirmed the diagnosis of gallstone ileus. Emergency exploratory laparotomy (choice C) is not indicated because the patient was hemodynamically unstable and would need a large amount of intravenous fluid to stabilize her blood pressure prior to surgery.

Discussion

Gallstone ileus is a mechanical obstruction caused by migration of a gallstone from the gallbladder through a biliary-enteric fistula into the gastrointestinal tract. A fistula typically occurs when inflammation from recurrent episodes of cholecystitis cause gallbladder adhesion to surrounding organs.2 In 85% of patients with gallstone ileus, gallstones travel through a cholecystoduodenal fistula into the duodenum, and 15% have a fistula that involves the stomach, small bowel, or transverse colon.1,2 Once in the gastrointestinal tract, gallstones typically advance distally and are expelled through the rectum, if they are small. Gallstones with diameter of 2 cm or greater may cause intestinal obstruction,1 which occurs most commonly in the ileum (50% to 60.5%) and less frequently in the jejunum, duodenum, colon, or stomach.2,3

Patients with gallstone ileus typically present with nausea, vomiting, abdominal pain, and distension, which may be intermittent as gallstones pass along the gastrointestinal tract.4,5 Rarely, an impacted gallstone can cause intestinal perforation.2

Gallstone ileus represents 1% to 4% of all cases of mechanical gastrointestinal obstruction but accounts for up to 25% of bowel obstruction in patients older than 65 years.5 Gallstone ileus occurs most commonly in older patients (mean age, 74 years),6 and 80% to 90% have multiple medical conditions,2 including hypertension, diabetes, and ischemic heart disease.7 Between 72% and 90% of patients with gallstone ileus are women,2and approximately 50% of patients have no history of gallbladder disease.1 An abdominal CT scan has a sensitivity of 93% and specificity of 100% for the diagnosis of gallstone ileus and is recommended for diagnostic imaging.8

Surgical treatment is typically recommended for patients with gallstone ileus because spontaneous resolution of intestinal obstruction is rare.1 Potential surgical procedures, performed using an open or laparoscopic approach, include extraction of the gallstone through an enterotomy (enterolithotomy) or enterolithotomy plus cholecystectomy and fistula closure performed in a single operation (1-step procedure) or in sequential operations (2-step procedure).2,8,9 Although no randomized clinical trials currently exist to support a preferred surgical treatment,7 enterolithotomy alone is the most commonly performed surgical procedure for gallstone ileus and has been associated with lower mortality rates and fewer immediate postoperative complications than alternative surgical options.2,8,9 However, a 1-step procedure may be considered for patients at low risk of surgical complications to decrease the likelihood of gallstone recurrence, retrograde cholecystitis, and gallbladder cancer.6

Recurrent gallstone ileus occurs in approximately 5% of patients treated with enterolithotomy, with 85% of recurrences occurring within 6 months of surgery.5 Despite surgical treatment, gallstone ileus is associated with a mortality rate of 7% to 30%, in part due to the advanced age and multiple medical comorbidities of most patients.6

Patient Outcome

The patient was admitted to the ICU and received 3 L of intravenous fluid resuscitation over 12 hours. The following day, her vital signs were within normal range and she underwent a midline laparotomy and enterolithotomy (Video), with removal of a 2.7-cm gallstone (Figure 2) that was obstructing the middle ileum. A 3-cm ileal resection with a hand-sewn side-to-side anastomosis was performed due to evidence of mild ischemic changes in the posterior wall of the ileum. The patient was monitored in the ICU for 3 days and discharged from the hospital on postoperative day 8. At a clinic visit 1 month later, she was asymptomatic, and her serum creatinine level was normal. She was referred to a hepatobiliary surgical specialist for follow-up and management of care.

Figure 2. Surgical removal of a 2.7-cm gallstone obstructing the middle ileum of a 70-year-old woman who presented to the emergency department with 3 days of nausea, vomiting, and abdominal pain.

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