Gallstone Ileus: A Case Study Report



77001371600540005431155Gallstone Ileus: A Case Study ReportPriority nutrition care distance dietetic internshipAleysia Kroptavich7900035000Gallstone Ileus: A Case Study ReportPriority nutrition care distance dietetic internshipAleysia Kroptavichright23002311402018760098002018Introduction:The patient I chose to study was diagnosed with a small bowel obstruction with Gallstone Ileus, and was NPO (Nothing by Mouth) with an NGT (Nasogastric tube) and a Foley while she was placed in the ICU for resuscitation and underwent a laparotomy the day after. I chose this patient because she was unique in that she had a very rare diagnosis, as well as a couple other serious medical complications going on. I met the patient when nutrition services received a consult from the physician to do COPD (Chronic Obstructive Pulmonary Disease) diet teaching with and an evaluation on her. It was a benefit to see her and learn about her case in the inpatient setting. She was admitted to the hospital due to vomiting profusely, crampy, intermittent abdominal pain and not being able to urinate. I respect this patient because she was her own best advocate in terms of making sure that she was receiving adequate nutrition, and remained positive in spite of her diagnosis. I enjoyed working with this patient due to her diversity compared to other patients I have worked with. I was able to converse with the patient about her tube feeding, and she was very approachable to the education I provided her. The GI tract is in my exploration, one that I’m interested in studying furthermore. Her diagnosis of Gallstone Ileus is an intestinal obstruction I have never heard of, so learning additional information about the obstruction and its treatment as well as how nutrition plays a role in it really interested me. By choosing this patient, I hope to educate myself about Gallstone Ileus and its conditions as well as treatments. Many patients I have had to assess had a history of a small bowel obstruction, but nothing like this. There is much to learn about the complications within the intestines and its proper treatments, because it encompasses quite a large variety of diseases. Discussion of Disease: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 (1). The first descriptions of gallstone ileus occurred in 1654 by Thomas Bartholin (1616-1680), a Danish physician, naturalist, physiologist, and anatomist. Bartholin described a cholecystointestinal fistula with a gallstone within the gastrointestinal tract in a necropsy study. In 1890, Ludwig Georg Courvoisier published the first series of 131 cases of gallstone ileus, with a mortality rate of 44%. In 1896, Léon Bouveret described a syndrome of gastric outlet obstruction caused by an impacted gallstone in the duodenal bulb after its migration through a cholecysto- or choledochoduodenal fistula. This was the first preoperative diagnosis of the currently known Bouveret’s syndrome (1).Among 1-4% of cases of intestinal obstruction are derived from this etiology, with women being more frequently affected. This entity has been observed with a higher frequency among the elderly, which accounts for up to 25% of non-strangulated bowel obstruction. The signs and symptoms of gallstone ileus are mostly nonspecific with intermittent symptoms of nausea, vomiting, abdominal distension, and pain (6). The intermittency of symptoms could also interfere with a correct diagnosis, if clinical manifestations at the moment correspond to a partial obstruction or distal migration of the gallstone. Patients usually present 4 to 8 days after the beginning of symptoms and diagnosis is usually made 3 to 8 days after the onset of symptoms. Cardiovascular, pulmonary, and metabolic diseases should be considered as they may affect the prognosis. Gallstone ileus is frequently led by an initial episode of acute cholecystitis. The inflammation in the gallbladder and surrounding structures leads to adhesion formation. The inflammation and pressure effects of the aberrant gallstone cause destruction through the gallbladder wall, leading to fistula formation between the gallbladder and the adjacent and adhered portion of the gastrointestinal tract, with further gallstone passage (7). The most common site of entry by erosion is thought to be to the duodenum (Bouveret’s syndrome). A gallstone may enter the duodenum through the common bile duct and through a dilated papila of Vater (9). However, large cholesterol stones can become impacted typically at the ileocecal valve. As such, gallstone ileus is a mechanical small bowel obstruction. Gallstone ileus may be manifested as acute, intermittent or chronic episodes of gastrointestinal obstruction. Nausea, vomiting, crampy abdominal pain and variable distension are commonly present. An intermittent nature of pain and vomiting of proximal gastrointestinal later on is due to the “tumbling” gallstone advancement (9,10). Thus, there may be intermittent partial or complete intestinal obstruction, with temporary advancement of the gallstone and relief of symptoms, until the gallstone either passes through the gastrointestinal tract or it definitively becomes impacted and complete intestinal obstruction arises (7,11). When the gallstone is in the stomach or upper small intestine, the vomitus is mainly gastric content, becoming feculent when the ileum is obstructed, therefore the character of the vomitus is dependent on the obstruction location. Physical examination may be broad. The patients are often acutely ill, with signs of dehydration, abdominal distension and tenderness with high-pitched bowel sounds and obstructive jaundice. Fever, toxicity and physical signs of peritonitis may be noted if perforation of the intestinal wall takes place. The presentation of gallstone ileus may be preceded by a history of prior biliary symptoms, with rates between 27%-80% of patients (5,6,10). Acute cholecystitis may be present in 10%-30% of the patients at the time of bowel obstruction. Jaundice has been found in only 15% of patients or less. Biliary symptoms may be absent in up to one third of cases (7,11,12).The main therapeutic goal is relief of intestinal obstruction by extraction of the offending gallstone. Fluid and electrolyte imbalances and metabolic derangements due to intestinal obstruction, delayed presentation and pre-existing co-morbidities are common, and require management prior to surgical intervention (5). Surgery is definitive, but there is no consensus on the indicated surgical procedure. The current surgical procedures are: (1) simple enterolithotomy; (2) enterolithotomy, cholecystectomy and fistula closure (one-stage procedure) and (3) enterolithotomy with cholecystectomy performed later (two-stage procedure). Bowel resection is necessary in certain cases after enterolithotomy is performed. An enterolithotomy has been the most common surgical procedure performed. Through an exploratory laparotomy, the site of gastrointestinal obstruction is localized. A longitudinal incision is made on the antimesenteric border proximal to the site of gallstone impaction (5,11). When possible, the gallstone is brought proximally to a non-edematous segment of bowel. Most of the times this is not possible due to the grade of impaction of the gallstone. The enterotomy is performed over the gallstone and it is extracted. Careful closure of the enterotomy is needed to avoid narrowing of the intestinal lumen and a transverse closure is recommended. The main long-standing controversy in the management of gallstone ileus is whether biliary surgery should be carried out at the same time as the relief of obstruction of the bowel (one-stage procedure), performed later (two-stage procedure) or not at all. Many patients with gallstone ileus are elderly, with comorbidities, in poor general condition and have a delayed diagnosis, leading to dehydration, shock, sepsis or peritonitis. Relief of gastrointestinal obstruction by simple enterolithotomy is the safest procedure for this population of patients as well as others with gallstone ileus (12).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 to supply necessary nutrients for healing. This is accomplished by nutrition support, which can be done either through an IV in the vein. This allows the bowel to rest while the underlying cause of the ileus is treated. IV feeding can be custom-mixed to provide an exact amount of calories, vitamins, trace minerals and fats. If infection is the cause, an antibiotic would be prescribed. Medications can be given to stimulate peristalsis, according to the National Institutes of Health (16).Presentation and Discussion of Patient: Mrs. L.L. was admitted to Wayne Memorial Hospital on October 29, 2018 with multiple issues including vomiting, GERD (Gastroesophageal Reflux Disease), crampy intermittent abdominal pain, lack of urination and COPD (Chronic Obstructive Pulmonary Disease). The patient is a 62 year old Caucasian female with a past medical history of a cancerous colon polyp, OSA (Obstructive Sleep Apnea), Arrhythmia, Gallstone ileus and a small bowel obstruction. Her family medical history was negative for diabetes, hypertension and CHF (Congestive Heart Failure). Her father had colon cancer as well as lymphoma. Her past surgical history included a laparotomy and surgery for the removal of a cancerous colon polyp. L.L.’s allergies include Penicillin. L.L. is 72” and weighs 268 lbs with a BMI of 36.3 kg/m^2. She denied any use of tobacco, alcohol or illicit drug use. L.L. is independent and has an active functional status. She is living at home with her spouse who she grocery shops and prepares meals with. L.L. did not state her profession or highest level of education completed.Day 1:On the day of admission at Wayne Memorial Hospital, the patients chief complaint was crampy, intermittent abdominal pain with vomiting. She presented herself to the ER because these conditions had been persisting for over 5 days. Her last reported bowel movement was on Thursday, October 25th and admitted to decreased urination on the day of admission. According to her initial assessment and CT scan of abdomen and pelvis, she was diagnosed with Gallstone Ileus. She appeared to have a mid-small bowel obstruction related to a 2.4 cm gallstone. From the CT, there appeared to be a moderate hiatal hernia and a severe fatty liver. The gallbladder was completely contracted. There was a small amount of gas in the lumen of the gallbladder as well as slight pneumobilia. The bladder was empty as well. The resulting physician’s plan was to make the patient NPO with an NGT (Nasogastric Tube) and a Foley, place in the ICU for resuscitation overnight and undergo a laparotomy the next day. A single organ ultrasound was ordered and found that the pancreas was not well seen due to overlying bowel gas. The liver demonstrated increased echogenicity. There did not appear to be any wall thickening in the gallbladder. The common bile duct measured 0.7 cm. and the right kidney measured 10.0 cm in length. Day 2:On day 2, or October 30, 2018, L.L. was NPO, so it was necessary per protocol for the registered dietitian to observe how long she’s NPO and what her nutritional needs are. L.L.’s calcium level on admission was 11.0 and was being managed for her recent diagnosis of Hypercalcemia. Her current diagnoses at this time were Gallstone Ileus, Hypercalcemia, Acute Kidney Injury (AKI), Leukocytosis, GERD, a heart murmur and Arrhythmia. For all of the medications during the patient’s hospitalization, refer to table 1. Her medications at this time, however, included Cetirizine Hydrochloride (10 mg daily), S Omeprazole (40 mg daily), Dulera inhaler (1 puff daily), Montelukast (10 mg daily) and Spiriva inhaler (twice daily). Because the patient was in a major surgical procedure this evening, she was not available for further questions regarding her lifestyle and general GI concerns. Her physician stated that her abdomen was soft, distended and showed some mild periumbilical tenderness. She showed no signs of cyanosis, clubbing or edema. Patient showed murmurs draining in both carotids in the neck and a 2-3/6 systolic ejection murmur at the left sternal border that radiates toward the apex. The second heart sound was faint; there was no diastolic murmur. An echocardiogram was conducted and showed sinus rhythm and minor nonspecific ST-T abnormality. L.L. showed impressions of a small bowel obstruction with gallstone ileus, a systolic murmur that suggested aortic stenosis with at least moderate severity and a history of some undisclosed arrhythmia. Table 1 – L.L.’s MedicationsMedication NameDose OrderedRouteStart/StopDrug ClassNutrition InteractionBenzocaine/Menthol1 lozQ4H PRNMT11/1/18 14:00N/AMay take w/ food if GI distress occurs.Decreased weight, increased appetite, increased thirst may occur.May cause N/V/D, constipationInfluenza Virus Vaccine Quadrival0.5 mlOnceIM11/1/18 09:0011/1/18 09:01VaccinesN/APotassium Chloride100 ml @ 50 mls/hrQ2HIV10/31/18 13:0010/31/18 14:59Replacement PrepSalt & Sugar SubTake with meals and 8 oz liquids.May cause GI irritation, N/V/D, abdominal painPantoprazole40 mgDailyIVP10/30/18 09:00Misc. GI DrugsTake with regard to food.May decrease absorption of Fe, decrease absorption of Vit B12.Decrease gastric acid secretion, increase gastric pH, N/D, abdominal painErtapenem 1 g/Sodium Chloride50 ml @ 100 mls/hrDailyIV10/30/18 09:0011/6/18 08:59Misc.May cause N/V, regurgitation, diarrhea, constipationRare- pseudomembranous colitis Sodium Chloride10 mlDailyIVP10/30/18 09:00Replacement Prep.Irrigating SolutionsN/AAcetaminophen100 ml @ 400 mls/hrQ8IV10/30/18AnalgesicsMay take regard to food. Food slightly delays abs of SR form. Caffeine may increase the rate of absorption.No GI bleedingHeparin Sodium (Porcine)5,000 unitsQ12SUBCUT10/29/18 21:00AnticoagulantsMay cause N/V, abdominal pain, GI bleed, constipation, black tarry stoolsOndansetron Base4 mgQ6H PRNIVP(for N/V)10/29/18 19:30Antiemetics May cause abdominal pain, dry mouth, constipation, diarrheaLactated Ringer’s1,000 ml @ 75 mls/hrAS DirectedIV10/29/18 19:30Replacement Prep.N/AHydromorphone HCl0.2 mgQ3H PRNIVP10/29/18 19:30Opiate AgonistsMay take with food to decrease GI distress.May cause weight loss, increased thirst and dehydration.Dry mouth, decreased gastric motility, N/V/D, constipation may occur.May interfere with amylase/lipase levels.Naloxone HCl0.4 mgProtocolOnce PRNIVP10/29/18 19:30Opiate AgonistsMay take tab w/ food to decrease GI distress.May decrease weight and increase thirst.N/V, abdominal pain, cramps, constipation, diarrhea may occur.Day 3:On day 3, 10/31/18, the physician wrote a progress note to the dietitian stating that the patient was still NPO and on NGT 700 but without the Foley since her urine output improved. Calcium level was 8.4 after IV fluid. The RD planned to monitor her nutritional intake closely since her intake the past three days was not consistent, therefore not nutritionally adequate. Day 4: On day 4, 11/1/18, the physician wrote a progress note stating that the patients abdomen was still soft and still mildly distended. The dressing had been cleaned and there was a plan to remove the NGT but maintain the patient on an NPO diet with IV fluids. L.L. consumed 100% of her meal this day at 20:36.Another physician met with L.L. later this day and stated that she had been examined at bedside for follow up of medical consultation for hypercalcemia. L.L.’s calcium level in her blood was above normal (11.0) when she was admitted, but her Hypercalcemia had been resolved (8.9). L.L. reported that she had not moved her bowels yet, but had passed flatus that afternoon. She stated her pain is well controlled. She had no chest pain or shortness of breath. L.L. had her heart examined and showed a regular rate and rhythm as well as systolic murmur. Her lungs appeared to be clear and she had positive bowel sounds. The physician followed in the periphery. Day 5:On day 5, 11/2/18, the physician wrote a progress note stating that L.L. felt well and her exam came back good. L.L. passed some flatus and was ambulating. She tolerated clear liquids and was able to advance to full liquids, per the physician and the dietitian. She consumed 100% of her meals at 08:38 and 09:52, 50% at 15:17 and 10% at 18:42. Even with the advanced diet order her intake was still not consistent. Day 6:On day 6, 11/3/18, L.L. had one episode of vomiting and felt shortness of breath (SOB) and needed her inhalers. She stated she had a small bowel movement and flatus. The physician kept the patient on full liquids and planned to advance her diet to regular the next day. She consumed 50% of her meal at 08:58, 100% at 13:24 and 10% at 18:18. The chosen nutrition diagnosis statement for this patient while working with her was 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. Day 7:On day 7, 11/4/18, L.L. stated she was feeling well. The physician wrote a progress note stating that her Afebrile VSS exam was good and planned on discharging her later on that day. The physician sent a consult to nutrition services to do COPD diet teaching with her and to document the evaluation before she could be discharged. I went out to conduct the teaching and advised her to consume smaller, more frequent meals and to drink plenty of fluids throughout the day to improve her COPD symptoms. For her diagnosis of gallstone ileus and how to prevent gallstones from reoccurring, I recommended her to eat a healthful diet with a balanced mix of plant-based foods, lose weight gradually as she does have an obese BMI and exercise regularly for at least 30 mins/day. L.L. did request weight management information and it was provided and reviewed. Research shows that these are ways to naturally prevent gallstones through diet. L.L. was attentive with the education I provided her. If her diet wasn’t able to be advanced and she was being discharged on a TPN regimen, the RD may have recommended a formula to use, how long she would need to run the tube for and how many mL of free water she would need per day. Fortunately, this was not the case. I was very much aware of her medical history and labs as she was an important patient for the RD to keep an eye on while she was in the hospital. One of the labs the RD really focuses on is a low albumin level. I noticed L.L.’s albumin was quite low throughout the course of her stay, so I calculated her IBW and %IBW to evaluate her for protein-calorie malnutrition (PCM). She was admitted weighing 268 lbs and her IBW is 130 lbs. When I divided her current weight of 268 lbs into her ideal of 130 lbs and multiplied by 100, her percent IBW calculated to be 206%. For someone to meet protein-calorie malnutrition, their IBW needs to fall in-between the range of 85-95%, have significant weight loss, a low albumin and/ or a document indicating poor intake. Fortunately, she did not meet for PCM and there was no need to complete an intervention for her. For all of her biochemical lab data during her hospital stay, refer to Table 2.Table 2 – Laboratory (Chemistry) NameResultDateSodium14510/31/18Potassium3.710/31/18Chloride111 H*High due to AKI.Could also be high from any dehydration or diarrhea. 10/31/18Carbon Dioxide28.010/31/18BUN1710/31/18Creatinine0.8110/31/18Est GFR (non-Af Amer)>60.010/31/18Glucose8510/31/18Lactic Acid1.410/29/18Calcium8.910/31/18Total Bilirubin0.6610/30/18AST2210/30/18ALT3710/30/18Alkaline Phosphatase10610/30/18Troponin I<0.0210/29/18Total Protein6.0 L*Low due to decreased amount of protein intake from being NPO.10/30/18Albumin2.7 L*Low due to her fatty liver.10/30/18Amylase17 L*May be due to overlying bowel gas on her pancreas. *Hydromorphone may have interfered with this level.10/29/18Lipase15010/29/18Procalcitonin0.210/29/18Discharge summary:L.L. was discharged to home the evening of 11/4 in good condition. Over the course of her stay at Wayne Memorial Hospital she was taken to the operating room after she was resuscitated and had an exploratory laparotomy with removal and repair of gallstone from small bowel. L.L. had a large amount of inflammation in her right upper quadrant that had been resolved. Post-operatively she remained on antibiotics for five days. She slowly improved and her diet was able to be advanced to a regular diet. Her estimated requirements are 1500 kcals/d and 60 g/d of protein, based on her IBW. Research:In a 2011 study by Davidovic, Tomic and Jorg, they 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 (13).In another study (2017) by Hangzhou, they 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). Additionally, patients with asymptomatic gallstones had a higher prevalence of NAFLD than in those without asymptomatic gallstones (58.98% vs 46.58%) (14). Summary: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 with the knowledge that she needed to adequately feed and hydrate herself regards to COPD and to prevent gallstones from reoccurring. She will follow-up with the physician and post discharge to evaluate her progress. Three lessons learned: Gallstone ileus is a rare form of small bowel obstruction caused by an impaction of a gallstone within the lumen (small opening) of the small intestine. Such a gallstone enters the bowel via a cholecysto-enteric fistula.A laparotomy is a surgical procedure involving a large incision through the abdominal wall to gain access into the abdominal cavity. It is also known as a celiotomy.A specific diet during the obstruction and after it is removed is recommended to allow the digestive system to heal, this includes:A clear liquid diet, which is monitored for any symptoms of diet intolerance such as vomiting, nausea and abdominal pain. This diet should only be followed short-term as it does not provide sufficient calories and protein.A full liquid diet, which is also limited in calories and protein, so high protein supplements may be recommended to support healing.A low fiber diet, which encourages diet tolerance and bowel healing. Foods low in fiber or with 3 g or less of fiber per serving is recommended on this diet.A regular diet, where one can gradually incorporate fiber-containing foods and should focus on drinking plenty of fluids, especially water. Bibliography1. Gaillard F. Gallstone ileus | Radiology Reference Article. . 2. Martin F. Intestinal obstruction due to gall-stones: with report of three successful cases. Ann Surg. 1912;55:725–743. [PMC free article] [PubMed]3. Reisner RM, Cohen JR. Gallstone ileus: a review of 1001 reported cases. Am Surg. 1994;60:441–446. [PubMed]4. Ayantunde AA, Agrawal A. Gallstone ileus: diagnosis and management. World J Surg. 2007;31:1292–1297. [PubMed]5. Fox PF. Planning the operation for cholecystoenteric fistula with gallstone ileus. Surg Clin North Am. 1970;50:93–102. [PubMed]6. VanLandingham SB, Broders CW. Gallstone ileus. Surg Clin North Am. 1982;62:241–247. [PubMed]7. Raiford TS. Intestinal obstruction due to gallstones. (Gallstone ileus) Ann Surg. 1961;153:830–838. [PMC free article] [PubMed]8. Warshaw AL, Bartlett MK. Choice of operation for gallstone intestinal obstruction. Ann Surg. 1966;164:1051–1055. [PMC free article] [PubMed]9. Masannat Y, Masannat Y, Shatnawei A. Gallstone ileus: a review. Mt Sinai J Med. 2006;73:1132–1134. [PubMed]10. Luu MB, Deziel DJ. Unusual complications of gallstones. Surg Clin North Am. 2014;94:377–394. [PubMed]11. Rodríguez-Sanjuán JC, Casado F, Fernández MJ, Morales DJ, Naranjo A. Cholecystectomy and fistula closure versus enterolithotomy alone in gallstone ileus. Br J Surg. 1997;84:634–637.12. Rogers FA, Carter R. Gallstone intestinal obstruction. Calif Med. 1958;88:140–143. [PMC free article] [PubMed]13. 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), 41?4. 14. Zhejiang, H. Nonalcoholic fatty liver was associated with asymptomatic gallstones in a Chinese population. 96(38);2017 Sept. [PMC free article] [PubMed] 15. Phillips S. Diet After Small Bowel Obstruction. . Published August 14, 2017. Accessed November 16, 2018.16. KODI - Login. . Accessed November 19, 2018. ................
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