L u is F e r n a n d o C o r r e a Z a n t u t , R e n a t a S e r g io P o g g e t t i, E lia n a S t e in m a n , D a r ia B ir o lin i
G a lls to n e ile u s a s a c a u s e o f u p p e r in te s tin a l o b s tru c tio n
E m e rg e n c y R o o m o f th e H o sp ita l d a s C lin ic a s, C o lle g e o fM e d ic ille ,U n iv e rsity o f S iio P a u lo (U S P ), T ra u m a S u rg e ry D isc ip lin e - S iio P a u lo , B ra zil
G a lls to n e ile u s , a m e c h a n ic a l in te s tin a l o b s tr u c tio n c a u s e d b y th e p a s s a g e o f a g a lls to n e in to th e in te s tin a l lu m e n th r o u g h a fis tu la , a lth o u g h n o t c o m m o n , d e s e r v e s to m o r e c a r e fu lly s tu d ie d d u e to its m o r b id ity a n d m o r ta lity . Its in c id e n c e a m o n g o ld e r - a g e g r o u p s e x p la in s its a s s o c ia tio n w ith c h r o n ic a n d d e g e n e r a tiv e d is e a s e s , w h ic h in c r e a s e th e c o m p le x ity o f th e tr e a tm e n t c h o ic e . T h e n e e d a n d a p p r o p r ia te n e s s o f a s u r g ic a l a p p r o a c h to a c h o le c y s te n te r ic fis tu la to s o lv e th e o b s tr u c tiv e e m e r g e n c y , in a o n e o r tw o s ta g e p r o c e -d u r e , h a s b e e n -d is c u s s e -d in th e lite r a tu r e . It h a s a ls o b e e n r e p o r te d th a t g a lls to n e ile u s is a n u n c o m m o n c a u s e o f u p p e r in te s tin a l o b s tr u c tio n . In te s tin a l o b s tr u c tio n is s e e n m o r e fr e q u e n tly a fte r a g a lls to n e im p a c ts a t th e ile o c e c a l v a lv e . T h e a u th o r s r e p o r t a c a s e o f g a lls to n e ile u s a s a c a u s e o f u p p e r in te s tin a l o b s tr u c tio n a n d d is c u s s its d ia g n o s is a n d tr e a tm e n t.
U N IT E R M S :ln te s tin a l o b s tr u c tio n . G a lls to n e ile u s . C h o le c y s te n te r ic ( b ilia r y - e n te r ic ) fis tu la .
IN T R O D U C T IO N
G a lls to n e ile u s is a m e c h a n ic a l o b s tr u c tio n c a u s e d
b y a g a lls to n e , o r g in a tin g in th e g a llb la d d e r , w h ic h p a s s e s
th r o u g h a c h o le c y s tie n te r ic f is tu la a n d im p a c ts in th e
in te s tin a l lu m e n . A n in c r e a s e in g a lls to n e ile u s , a s s o c ia te d
w ith in c r e a s in g lo n g e v ity , h a s b e e n o b s e r v e d in d e v e lo p e d
c o u n tr ie s o v e r th e p a s t s e v e r a l y e a r s . G a lls to n e ile u s
a c c o u n ts f o r 1 -4 p e r c e n t o f a ll in te s tin a l o b s tr u c tio n s . 1 -3
S u c h in c id e n c e is s ta tis tic a lly s ig n if ic a n t in p a tie n ts
o v e r 7 0 , p r e d o m in a te ly w o m e n . I n 8 0 - 9 0 p e r c e n t o f th e
c a s e s in th is a g e g r o u p , p a tie n ts a ls o h a v e a s s o c ia te d
d is e a s e s w h ic h a f f e c t o n e o r m o r e s y s te m s , m a in ly
c a r d io v a s c u la r d is e a s e s a n d d ia b e te s m e llitu s .1 .2 .4 - 6
A d r e s s f o r c o r r e s p o n d e n c e : L u is F e r n a n d o C o r r e a Z a n t u t
A v , B r ig . L u is A n t o n io , 4 5 2 1 -J a r d im P a u lis t a S a o P a u lo / S P - B r a s il - C E P 0 1 4 0 1 - 0 0 2
M o r ta lity r a te s v a r y b e tw e e n 1 2 - 2 7 p e r c e n t, w ith d e a th s
b e in g r e la te d to c r itic a l c o n d itio n s , a n d e s p e c ia lly to th e s e
a s s o c ia te d d is e a s e s . 1 0 4 .7
M o s t g a lls to n e s c a u s e o b s tr u c tio n b y im p a c tin g th e
d is ta l ile u m .H) .7 T r e a tm e n t r e m a in s c o n tr o v e r s ia l in r e g a r d s
to th e tr u e n e e d to r e a c h th e c h o le c y s te n te r ic f is tu la d u r in g
in itia l o p e r a tiv e p r o c e d u r e s .IA •X•lJ
T h e o b je c tiv e s o f th is r e p o r t a r e to d e s c r ib e a n u p p e r
in te s tin a l o b s tr u c tio n b y g a lls to n e ile u s , d ia g n o s e d
p r e o p e r a tiv e ly b y c o m p u te r iz e d to m o g r a p h y ( C T ) ; a n d to
d is c u s s th e a d e q u a c y o f th e in s titu te d tr e a tm e n t.
C A S E D E S C R IP T IO N
A n 8 0 - y e a r o ld p a tie n t, w ith m ild c a r d ia c f a ilu r e a n d
a h is to r y o f tw o p r e v io u s s tr o k e s th a t h a d le f t m in im a l
s e q u e la e , w a s a d m itte d to a n o th e r h o s p ita l. S h e h a d b e e n
v o m itin g f o o d r e s id u e s f o r f o u r d a y s , a n d h a d h a d n o p r io r
s y m p to m s o f c h o le c y s to p a th y .
S Z A J N B O K , I.; L O R E N Z I, E ; R O D R IG U E S J r ., A .J .; Z A N T U T , L .E G .; S T E IN M A N , E .; P O G G E T II, R .S . & B IR O L lN I, D . - G a lls to n e ile u s a s a c a u s e o f u p p e r in te s tin a l o b s tr u c tio n
A n u p p er d ig estiv e en d o sco p y sh o w ed g astric an d d u o d en al fo o d stasis an d acu te g astro d u o d en itis. In th e fo llo w in g d ay s, in ad d itio n to a sim p le ro en to g en o g ram o f th e ab d o m en , an u lstraso n o g rap h y an d a C T scan w ere p erfo rm ed . E x am s sh o w ed air in th e b ile tree, n o sto n es in th e g allb lad d er, th ick en ed d u o d en al w alls, an d a rad io p aq u e
im ag e su g g estin g an im p acted sto n e at T reitz' arch (F ig . 1 ). T h e p atien t th en b eg an to co m p lain o f ab d o m in al
p ain an d d isten tio n , a w o rsen in g o f th e v o m itin g , an d a sto p p ag e o f g as an d fecal elim in atio n . A fter w ard s, sh e w as tran sferred to o u r h o sp ital. A d m itted sev en d ay s after th e o n set o f th e sy m p to m s, sh e w as an icteric, afeb ri Ie, an d p resen ted sig n s o f in testin al o b stru ctio n .
A fter p reo p erativ e p rep aratio n , sh e w as su b m itted
to a lap aro to m y . A ch o lecy sto d u o d en al fistu la an d a 3 .5 cm im p acted g allsto n e w ere fo u n d in th e d istal jeju n u m . T h e g allsto n e frag m en ted d u rin g m an ip u latio n , so a m an u al p ro p u lsio n o f th e frag m en ts an d th e co n ten ts o f th e co lo n w as p erfo rm ed .
A s th e p atien t's co n d itio n w as. fav o rab le, ch o lecy stecto m y an d a tran sv erse su tu re o f th e d u o d en u m w ere carried o u t at th e fistu la site. D u rin g su rg ery , a
rad io g rap h ic ev alu atio n o f th e b ile d u cts w as n o rm al, an d th e p erito n eal cav ity w as d rain ed . T o tal tim e u n d er an esth esia w as six h o u rs, an d n o b lo o d tran sfu sio n w as n ecessary . T h e p atien t sh o w ed a d y n am ic ileu s fo r fiv e d ay s w ith n o o th er co m p licatio n s. S h e w as d isch arg ed o n d ay 1 3 .
D I S C U S S I O N
G allsto n e ileu s clin ical fin d in g s are v ariab le. S y m p to m s m ay b eg in 4 -8 d ay s p rio r to in testin al o b stru ctio n . T h ese in itial sy m p to m s m ay reflect th e
in term itten t m ig ratio n o f th e g allsto n e u n til fin al im p actio n , w h ich u su ally o ccu rs n ear th e ileo cecal v alv e.I.U i.7
In th e p resen t case, th e clin ical fin d in g s su g g est m u ltip le
m ig ratio n s alo n g th e sm all in testin e. S u ch m ig ratio n s w o u ld acco u n t fo r th e v ariab le sy m p to m s p resen ted b y o u r p atien t, an d th e su rg ical fin d in g o f th e sto n e d istally fro m th e site in d icated b y th e p reo p erativ e C T scan .
P A T H O P H Y S I O L O G Y
B iliary -en teric fistu las h av e m an y k n o w n cau ses. O n e
o f th em is a d u o d en al u lcer p erfo rated in to th e b ile d u cts, w h ich sh o u ld n o t b e m istak en fo r ch o lecy sten teric fistu las,
F ig u r e 1 - A b d o m in a l c o m p u t e r iz e d t o m o g r a p h y : A ir in t h e b ile t r e e a n d a 3 . 5 c m im a g e w it h p e r ip h e r a l la m in a r a n d c r u d e c e n t r a l
c a lc if ic a t io n s , c o r r e s p o n d in g t o a n im p a c t e d g a lls t o n e a t t h e le v e l o f T r e it z ' a r c h .
w h ich are co n seq u en ces o f rep eated in flam m ato ry ep iso d es in th e g allb lad d er.
T h ese ep iso d es cau se p erich o lecy stitis an d ad h eren ce
to n eig h b o rin g o rg an s. U lceratio n d u e to im p actio n o n th e g allb lad d er w all m ay , b y its co n tig u ity , affect th e ad h ered b o w el w all. T h is w o u ld allo w th e g allsto n e to p ass in to th e in testin al lu m en .
C L I N I C A L M A N I F E S T A T I O N S
A b o u t o n e-th ird o f p atien ts d o n o t rep o rt p rev io u s
sy m p to m s o f b ile d isease, an d o n ly o n e-th ird rep O lt ep iso d es th at co u ld b e related to recen t acu te ch o lecy stitis.2.5 .7 .1 0 In
sp ite o f th e d ifficu lties in g ath erin g d ata o n o u r p atien t's h isto ry , it w as p o ssib le to co n clu d e th at sh e h ad n o t p resen ted an y p rev io u s sy m p to m s o f b ile d isease p rio r to th is ev en t.
A g allsto n e th at p asses th ro u g h a fistu la m ay b e elim in ated th ro u g h v o m itin g o r feces, o r m ay b eco m e lo d g ed an d o b stru ct th e in testin al lu m en . G allsto n e ileu s freq u en tly cau ses co lick y ab d o m in al p ain , b ilio u s o r ev en tu ally fecal v o m itin g , an d , rarely , jau n d ice. A d ifferen tial d iag n o sis in v o lv es o th er cau ses o f sm all b o w el o b sfru ctio n an d m esen teric isch em ia.
S a o P a u lo M e d ic a l J o u r n a l/ R P M 1 1 4 ( 4 ) : 1 2 3 9 - 1 2 4 3 , 1 9 9 6 S Z A J N B O K , I . ; L O R E N Z I , E ; R O D R I G U E S J r . , A . J . ; Z A N T U T , L . E C . ; S T E I N M A N , E . ;
P ro m p t d ia g n o s is is n o t a lw a y s p o s s ib le , a n d in s o m e c a s e s , d ia g n o s is is c o n firm e d o n ly d u rin g la p a ro to m y . S o m e a u th o rs re p o rt s u rg ic a l p ro c e d u re s c a rrie d o u t 3 - 5 d a y s a fte r a d m is s io n , d u e to d ia g n o s tic d iffic u ltie s o r th e n e e d to s ta b iliz e a n y a s s o c ia te d o rg a n ic fa ilu re .3 .4 .IO .ll
L A B O R A T O R Y E X A M S
C lin ic a l fin d in g s a re c o n firm e d b y ro e n tg e n o g ra m s , u ltra s o n o g ra p h ie s , C T , a n d u p p e r d ig e s tiv e e n d o s c o p y . S im p le a b d o m in a l ro e n tg e n o g ra m s o f g a lls to n e c a n b e e v a lu a te d fo r .R ig le r's tria d : m e c h a n ic a l o b s tru c tio n , a ir in th e b ile tre e , a n d a n u s u a lly -lo c a te d o r m ig ra tin g ra d io p a q u e s to n e .2 .1 2 .1 3 T w o o f th e s e s ig n s a p p e a r in a t le a s t h a lf o f g a lls to n e ile u s p a tie n ts .
A ir in th e b ile tre e is fre q u e n tly re la te d to p re v io u s b ile d u c t la p a ro to m y o r to th e fa ilu re o f th e O d d i's s p h in c te r. F o r th is to o c c u r, th e c y s tic d u c t m u s t b e p e rv io u s o r th e re m u s t a fis tu la le a d in g in to th e b ile d u c t. A n o th e r ra d io g ra p h ic s ig n is th e o b s e rv a tio n o f tw o a ir-flu id le v e ls in th e rig h t s u b c o s ta l re g io n ; th e m e d ia l o n e is th e d u o d e n u m a n d th e la te r o n e is th e g a llb la d d e r. T h e p re s e n c e o f g a s e s o v e r th e g a llb la d d e r fre q u e n tly m a k e s th is s ig n d iffic u lt to s e e .
A c o n tra s te d ro e n tg e n o g ra m m a y id e n tify th e fis tu la a n d th e le v e l o f m e c h a n ic a l o b s tru c tio n .
A b d o m in a l u ltra s o n o g ra p h y d e te c ts c h o le c y s te n te ric fis tu la s , re s id u a l c h o le lith ia s is , a n d im p a c te d g a lls to n e s . 1 .1 0 .1 2H o w e v e r, tw o fa c ts m u s t b e re m e m b e re d :
I . R e s id u a l c h o le lith ia s is m a y n o t o c c u r, a n d 2 . Its p re s e n c e m a y n o t b e d e te c te d b y u ltra s o n o g ra p h y .
A n a b d o m in a l C T m a y s h o w g a lls to n e s n o t d e te c te d in th e ro e n tg e n o g ra m o r u ltra s o n o g ra p h y . It c a n id e n tify g a s o r c o n tra s t in th e b ile d u c ts o r g a llb la d d e r, in te rp re te d a s s ig n s o f b ilia ry -e n te ric fis tu la .'2
G a lls to n e s m a y b e id e n tifie d a n d re m o v e d d u rin g e n d o s c o p y . O th e rw is e , la p a ro to m y is re q u ire d .'
D I A G N O S I S
In th is c a s e , a s y n d ro m ic d ia g n o s is w a s o b ta in e d c lin ic a lly fo llo w in g th e d e v e lo p m e n t o f s ig n s a n d s y m p to m s c le a rly in d ic a tin g o b s tru c tio n . A s th e s im p le
ra d io g ra p h ic im a g e w a s u n c le a r, th e e tio lo g ic d ia g n o s is w a s c o n firm e d o n ly th ro u g h C T . R ig le r's tria d w a s la te r id e n tifie d o n th e ro e n tg e n o g ra m .
S U R G I C A L T R E A T M E N T
G a lls to n e ile u s s h o u ld b e p re fe re n tia lly tre a te d b y la p a ro to m y . It is a ls o p o s s ib le to re m o v e s o m e o b s tru c tio n s b y e n d o s c o p y , a n d re p o rte d ly in a fe w c a s e s , b y s h o c k -w a v e lith o trip s y . I
Im p a c te d g a lls to n e s a re re p O lte d to b e fo u n d m o s tly in th e s m a ll in te s tin e , a n d a re n o t c o m m o n in th e c o lo n . A c c o rd in g to s e v e ra l a u th o rs , o b s tru c tio n s o c c u r in 5 0 - 7 0
p e rc e n t o f th e c a s e s w ith in th e d is ta l ile u m , in c lu d in g th e ile o c e c a l v a lv e , 2 0 - 4 0 p e rc e n t in th e p ro x im a l ile u m o r je ju n u m , a n d th e o th e r 1 0p e rc e n t o c c u r in th e d u o d e n u m .1 .I4 .'5 T h e m o s t c o m m o n o b s tru c tio n s ite in th e c o lo n is th e s ig m o id . T h is u s u a lly o c c u re s b e c a u s e o f th e p re s e n c e o f a c h o le c y s to c o lo n ic fis tu la a n d a p re v io u s s ig m o id c o lo n s tric tu re c a u s e d b y a p a s t d iv e rtic u litis c ris is . C a lc u li c a p a b le o f c a u s in g o b s tru c tio n w o u ld h a v e n o t b e e n a b le to p a s s th ro u g h th e ile o c e c a l v a lv e w ith o u t th e p re s e n c e o f a c o lo n ic fis tu la .'4 .1 5 In m o s t c a s e s , th e re is o n ly o n e o b s tru c tiv e g a lls to n e , w h ic h v a rie s fro m 2 - 5
c m in d ia m e te r. 1 .7 .1 1 .1 4
T h e m o s t c o m m o n fis tu la s a re , in d e c re a s in g o rd e r o f fre q u e n c y : c h o le c y s to d u o d e n a l; c h o le c y s to c o lo n ic ; c h o le c y s to d u o d e n o c o lo n ic ; a n d c h o le d o c h o d u o d e n a l. C o lo n ic fis tu la s o c c u r m o re fre q u e n tly in th e h e p a tic fle x u re , th e tra n s v e rs e c o lo n , a n d u n c o m m o n ly , in th e s ig m o id c o lo n .2 .'li
E a rly re c u rre n c e h a p p e n s w h e n th e re a re m u ltip le g a lls to n e s a n d th e fis tu la h a s b e e n in a d e q u a te ly tre a te d . M u ltip le g a lls to n e s a re u s u a lly m u ltifa c e te d .
S in c e th e m ig ra tio n o f tw o o r m o re g a lls to n e s is . p o s s ib le , in s p e c tio n o f a ll in te s tin a l s e g m e n ts d u rin g
s u rg e ry is re c o m m e n d e d .x .1 3 .lli.1 7
T h e lite ra tu re o n g a lls to n e ile u s d is c u s s e s th re e ty p e s o f s u rg ic a l o p tio n s :
1 . E n te ro lith o to m y , fo llo w in g re m o v a l o f th e o b s tru c tio n .
2 . A tw o s ta g e p ro c e d u re - th e firs t s ta g e is e n te ro lith o to m y , a n d , 3 o r 4 w e e k s la te r, c h o le c y s te c to m y a n d re m o v a l o f th e c h o le c y s te n te ric fis tu la .
3 . A o n e -tim e la p a ro to m y , in c lu d in g e n te ro lith o to m y a n d c h o le c y s te c to m y w ith re m o v a l o f th e fis tu la .
C rite ria w h ic h s h o u ld g u id e tre a tm e n t a re : a g e ; a c id / b a s e a n d h y d ro e le c tro ly tic e q u iii b ri u rn ; a s s o c i a te c !
S Z A J N B O K , I . ; L O R E N Z I , F . ; R O D R I G U E S J r . , A . J . ; Z A N T U T , L . F . C . ; S T E I N M A N , E . ; P O G G E T T I , R . S . & B I R O L l N I , D . - G a l l s t o n e i l e u s a s a c a u s e o f u p p e r i n t e s t i n a l o b s t r u c t i o n
d is e a s e s ; re s id u a l c h o le lith ia s is ; a n d th e p re s e n c e o f a c u te
in fla m m a tio n in th e c h o le c y s te n te ric fis tu la .3 .x.
"
SURGICAL
TECHNIQUES
E n te ro lith o to m y s h o u ld b e d o n e th ro u g h a
lo n g itu d in a l in c is io n p ro x im a te to th e o b s tru c tio n a t th e
a n tim e s e n te ris b o rd e r, fo llo w e d b y a tra n s v e rs e s u tu re .
E v e n tu a lly , a n e n te re c to m y w ill b e n e c e s s a ry , p a rtic u la rly
if th e re is a n in te s tin a l p e rfo ra tio n .
M a n u a l p ro p u ls io n o f th e c e c u s a n d g a lls to n e trip s y
m a y b e p e rfo rm e d o n ly in s e le c te d c a s e s , a s th e re is a ris k
o f in ju ry to th e b o w e l w a ll.l.lX
In th e c a s e o f m u ltip le g a lls to n e s , a n in c is io n n e x t to
th e la rg e s t o n e s p e rm its th e e x tra c tio n o f th e s m a lle r o n e s .
In s ig m o id c o lo n o b s tru c tio n , a u th o rs d e s c rib e .
p ro x im a l c o lo to m y fo r s to n e re m o v a l, ju s t a s in e x tra c tio n
b y c o lo n o s c o p y . H o w e v e r, w h e n th e s ig m o id c o lo n is
n a rro w e d , re s e c tio n is p re fe rre d , w ith th e re m o v a l o f th e
s e g m e n t w ith th e s to n e s .14
•1 5
In th is c a s e , th e a b s e n c e o f re s id u a l s to n e s w a s
d e m o n s tra te d b y p re o p e ra ti v e e x a m s , a n d th u s a tw o -s ta g e
la p a ro to m y c o u ld h a v e b e e n c o n s id e re d . H o w e v e r, a s
c lin ic a l c o n d itio n s p e rm itte d , a o n e -s ta g e p ro c e d u re w a s
c h o s e n . T h e s a tis fa c to ry e v o lu tio n o f th e p a tie n t c o n firm e d
th e a p p ro p ria te n e s s o f th e th is tre a tm e n t.
It s h o u ld b e n o te d th a t, a lth o u g h m a n u a l p ro p u ls io n
o f s to n e s is n o t u s u a lly re c o m m e n d e d , d u e to th e ris k o f
tis s u e in ju ry a n d d is ta l o b s tru c tio n o f th e s ig m o id c o lo n ,
it w a s d o n e in th is c a s e b e c a u s e o f th e fra g m e n ta tio n o f
th e s to n e a fte r m a n ip u la tio n .
POSTOPERATIVE
RESULTS
S p o n ta n e o u s c lo s in g o f th e c h o le c s y te n te ric
fis tu la m a y o c c u r a fte r g a lls to n e m ig ra tio n , w h e n th e re
a re n o re s id u a l c a lc u li a n d th e c y s tic d u c t is
p e rv io u s .lJ .'lJ .2 o W h e n c h o le c y s te c to m y a n d c o rre c tio n
o f th e b ilia ry -e n te ric fis tu la a re n o t p e rfo rm e d , s o m e
c o m p lic a tio n s m a y re s u lt, s u c h a s : c h o la n g itis ; a c u te
c h o le d o c h o c y s ti tis ; re c u rre n t i n te s ti n a l o b s tru c tio n ;
c h o le d o c h o lith ia s is ; fis tu ra l b le e d in g ; a n d g a llb la d d e r
c a rc in o m a .
C h o la n g itis o c c u rs in 10 p e rc e n t o f th e c a s e s
w ith c h o le c y s te n te ric fis tu la p e rs is te n c e , a n d in 6 0
. p e rc e n t o f th o s e w ith c h o le c s y te n te ric fis tu la . A c u te
c h o le d o c h o c y s titis m a y o c c u r d u e to re s id u a l
c h o le lith ia s is , a n d re c u rre n t g a lls to n e s c a n b e
o b s e rv e d in 5 -1 0 p e rc e n t o f th e c a s e s . C h o le lith ia s is
m a y a ls o c a u s e c h o la n g itis . B le e d in g m a y o c c u r d u e
to p a s s a g e o f th e g a lls to n e th ro u g h th e fis tu la . T h e
in c id e n c e o f g a llb la d d e r c a rc in o m a in p a tie n ts w ith
p e rs is te n c e is 15 p e rc e n t, c o m p a re d to 0 .8 p e rc e n t in
th e g e n e ra l p o p u la tio n .5 .'7 .'lJ .2 o
CONCLUSION
T h e d e fin ite c o rre c tio n o f th e b ile d u c t d o e s n o t
in c re a s e m o rta lity in re la tio n to o th e r fo rm s o f tre a tm e n t,
in s p ite o f th e in c re a s e d a n e s th e s ia /s u rg e ry tim e .IM I.X .1 1
T h e o n e -s ta g e p ro c e d u re s e e m s to b e in d ic a te d w h e n
lo c a l a n d s y s te m ic c o n d itio n s p e rm it. T h e tw o -s ta g e
p ro c e d u re d o e s n o t ra is e m o rta lity , b u t it d o e s m e a n a
lo n g e r h o s p ita l s ta y , a s it in v o lv e s tw o d iffe re n t p ro c e d u re s ,
u s u a lly o n a e ld e rly p a tie n t.
W h e n b ile d u c t c o rre c tio n is n o t p o s s ib le d u rin g
in itia l s u rg e ry , b ile d is e a s e o r re s id u a l c h o le lith ia s is
s y m p to m s ju s tify a s u b s e q u e n tly p ro g ra m m e d
re in te rv e ritio n .
P a tie n ts w h o re m a in a s y m p to m a tic a n d w ith o u t a n y
v is ib le s to n e s a fte r e n te ro lith o to m y m a y b e fo llo w e d u p
b y a s e rie s o f u ltra s o n o g ra p h ie s , in s te a d o f u n d e rg o in g
a n o th e r s u rg e ry .
In h ig h -ris k p a tie n ts , w h o a fte r e n te ro lith o to m y s till
h a v e re s id u a l c o le th ia s is , s h o c k w a v e Ii th o tri p s y o r
c h e m ic a l d is s o lu tio n o f th e s to n e s s h o u ld b e c o n s id e re d .
H o w e v e r, fu rth e r s tu d ie s a re n e e d e d o n th e re p e rc u s s io n s
o f th e s e tre a tm e n ts o n c h ro n ic a lly -in fla m e d a re a s , s u c h a s
th o s e fo u n d ,in c h o le c y s te n te ric fis tu la s . I
Sao Paulo M edical Journal/RPM 114(4): 1239-1243, 1996 SZAJNBOK, I.; LORENZI, F.; RODRIGUES Jr., A.J.; ZANTUT, L.F.C.; STEINM AN, E.;
RESUMO
O b je tiv o : O s a u to re s a p re s e n ta m c a s o d e fle o b ilia r c o m o c a u s a d e o b s tru y a o m e c fm ic a a lta , d is c u tin d o a s p e c to s re fe re n te s
a o d ia g n 6 s tic o e tra ta m e n to . D is c u s s a o e R e s u lta d o s : A o b s tru y a o in te s tin a l m e c a n ic a c a u s a d a p e la p a s s a g e m d e c a lc u lo d a
v e s ic u la b ilia r p a ra a lu z in te s tin a l a tra v e s d e fis tu liz a y a o , a p e s a r d e in fre q u e n te , m e re c e e s tu d o p e la m o rb i-m o rta lid a d e q u e
a p re s e n ta . A in c id e n c ia e m fa ix a s e ta ria s m a is a v a n y a d a s e x p lic a a a s s o c ia y a o c o m d o e n y a s c r6 n ic o -d e g e n e ra tiv a s , a u m e n ta n d o
a c o m p le x id a d e d a d e c is a o te ra p e u tic a . A lite ra tu ra d is c u te a n e c e s s id a d e e a o p o rtu n id a d e d a a b o rd a g e m c iru rg ic a d a fis tu la
c o le c is to -e n te ric a e m u m o u d o is te m p o s d ia n te d a re s o lu y a o d a u rg e n c ia o b s tru tiv a e fa z re fe re n c ia d o fle o b ilia r s e n d o a
c a u s a d e o b s tru y a o in te s tin a l a lta c o m o e x c re y a o . A o b s tru y a o in te s tin a l v e rific a d a c o m m a io r fre q u e n c ia o c o rre q u a n d o d a
im p a c ta y a o d o c a lc u lo b ilia r a n iv e l d a v a lv u la i1 e o -c e c a l.
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