General1 Edward
B. Zinkin,
MD
#{149} William
M. Brammer,
MD
U HISTORY A 66-year-old man presented with low ab. dominal pain, urinary frequency, and fever of 3 days duration. He had undergone repair of a right inguinal hernia the preceding month, and the wound was described as “clean and healing well.” Laboratory studies revealed a leukocyte count of 1 5,800/mm3 (1 5 .8 X 1 09/L), with 63% granubocytes, 17%
bands, and 14% lymphocytes. try values were normal. The
Serum original
#{149} Clare
sient
obstruction
chemisurine
U
abdominal
four,
barge,
From the
1988 C RSNA.
1108
U
the
1990; Department
RSNA 1990
scientific
RadioGrapbics
calculi,
4.81,
62.289
intestines,
#{149}
deveb-
radiograph
faceted,
demonstrated
calcified
stones
overly-
ing the sacrum (Fig 1) No bowel gas was seen adjacent to these stones non within the gallbladder or biliary ducts. There was no radiographic evidence of mechanical bowel obstruction. The CT scan of the abdomen demonstrated multiple, faceted gallstones and an associated mass with heterogeneous attenuation vabues representing an abscess (Fig 2) The .
.
were
Gallbladder,
bowel
was suspected clinically, was added to the antibiotthe CT study (Fig 2) was
FINDINGS
The
stones terminal
terms:
of the small
oped. Diverticulitis and metronidazole ic regimen before performed.
was lost, and another specimen was not obtained until after the patient had begun taking ampicillin and gentamicin subfate for sepsis secondary to a urinary tract infection. The urine specimen showed 2-5 white blood cells per high-power field, 0-2 red blood cells per high-power field, granubar cell casts, and urobilinogen. An abdominal radiographic series was performed (Fig 1), and abdominal CT was on-
RadioGraphics
MD
demed to rule out a postoperative abscess. On the 2nd day after admission, the pain localized to the left lower quadrant, and a tran-
collection
Index
A. Colombo,
and
abscess were in the region ileum. No gas or additional seen within the biliary system.
perforation.
74.71
General
Hospital,
of the stones
10:1108-1110 of Radiology assembly.
U
and
Nuclear
Received
Zinkin
and
Imaging,
Rochester
accepted
October
et al
27,
1989.
Address
1 425 reprint
Portland requests
Ave.
Rochester, to
Ns’
1 462
1 . From
E.B.Z.
Volume
10
Number
6
Figure
1.
Supine
radiograph
of the abdomen.
Figure 2. CT scans of the abdomen obtained after intravenous and oral administration of contrast material.
November
1990
Zinkin
et al
U
Ra4ioGrapbics
U
1109
DIAGNOSIS: Gallstone perforation of the terminal ileum with abscess formation.
U DISCUSSION Numerous calcified gallstones may be seen in the lower abdomen, particularly the night lower quadrant. The faceted appearance of these stones, particularly when large and
multiple,
is characteristic
of gallstones
(1).
Differential diagnosis includes entemoliths, ureteral calculi, and bladder stones. Appendicoliths and entenobiths, secondary to a small bowel stricture in Crohn disease or tuberculosis, are usually solitary and, when radiopaque, will demonstrate lamellar calcifications (2) Gallstones within the gallbladden are usually more cephalic unless severe hepatomegaly, with secondary depression of the hepatic flexume of the colon, is also present. Ureteral calculi are usually associated with hydronephnosis of the kidney, as seen with CT. Bladder calculi, which might develop in a urachal remnant, would be .
smooth
and
located
bladder
and
umbilicus,
non
abdominal
between
the dome
adjacent in the might of the common
lions
ileus.”
The
ante-
1110
U
RadioGrapbics
formed, the patient rare syndrome that diagnose: recurrent U
.
Gallstone
characteristics
U
Zinkin
ileus
when
the stone
per-
is at risk of developing is even more difficult gallstone ileus (4).
is an ob-
et al
.
REFERENCES Hermanutz
D, Beta
L, Linzbach
Gallstone ileus. Radiol 12: 185-188. [German]
lower quadmanifesta-
of the classic case include mechanical small bowel obstruction (in 86% of such cases), gas in a contracted gallbladder or in the biliany ducts (60%) , and visualization of ectopic gallstones (25%) (3). The simultaneous occurrence of all three diagnostic features is name (3)
resolved
forated the terminal ileum. A transient obstruction occurred 1 day after abdominal madiography and before CT was performed. The second criterion of the syndrome, gas within the biliary system, was never observed, even on the CT scan. Stones were palpated within the gallbladder during surgical exploration. As no cholecystectomy was per-
1
Ectopic gallstones rant represent one
considered
spontaneously
a to
of the
to the
wall.
of “gallstone
vious misnomer, referring to the most frequent characteristic, small bowel obstruction. The obstruction is usually in the distal ileum due to a large stone that has eroded through the gallbladder into the duodenum or, less commonly, the stomach. This infrequent syndrome is said to account for 2%-5% of all cases of mechanical small bowel obstruction in the elderly population (1). By convention, our patient was also considered to have gallstone ileus. He presumably had a small bowel obstruction that
2.
Margulis radiology.
3.
EisenmanJl,
1983;
4.
Univ
C, Gerlack KIm
F.
1972;
AR, Burhenne HJ. Alimentary tract Vol 2. 3rd ed. St Louis: Mosby, 1655.
Finck
EJ, O’Loughlin
BJ.
stone ileus: a review of the roentgenographic findings and a report of a new roentgen AJR 1967; 101:361-366. Ulneich S, MassiJ. Recurrent gallstone AJR 1979; 133:921-923.
Volume
Gallsign. ileus.
10
Number
6
B. Zinkin,
MD
#{149} William
M. Brammer,
MD
U HISTORY A 66-year-old man presented with low ab. dominal pain, urinary frequency, and fever of 3 days duration. He had undergone repair of a right inguinal hernia the preceding month, and the wound was described as “clean and healing well.” Laboratory studies revealed a leukocyte count of 1 5,800/mm3 (1 5 .8 X 1 09/L), with 63% granubocytes, 17%
bands, and 14% lymphocytes. try values were normal. The
Serum original
#{149} Clare
sient
obstruction
chemisurine
U
abdominal
four,
barge,
From the
1988 C RSNA.
1108
U
the
1990; Department
RSNA 1990
scientific
RadioGrapbics
calculi,
4.81,
62.289
intestines,
#{149}
deveb-
radiograph
faceted,
demonstrated
calcified
stones
overly-
ing the sacrum (Fig 1) No bowel gas was seen adjacent to these stones non within the gallbladder or biliary ducts. There was no radiographic evidence of mechanical bowel obstruction. The CT scan of the abdomen demonstrated multiple, faceted gallstones and an associated mass with heterogeneous attenuation vabues representing an abscess (Fig 2) The .
.
were
Gallbladder,
bowel
was suspected clinically, was added to the antibiotthe CT study (Fig 2) was
FINDINGS
The
stones terminal
terms:
of the small
oped. Diverticulitis and metronidazole ic regimen before performed.
was lost, and another specimen was not obtained until after the patient had begun taking ampicillin and gentamicin subfate for sepsis secondary to a urinary tract infection. The urine specimen showed 2-5 white blood cells per high-power field, 0-2 red blood cells per high-power field, granubar cell casts, and urobilinogen. An abdominal radiographic series was performed (Fig 1), and abdominal CT was on-
RadioGraphics
MD
demed to rule out a postoperative abscess. On the 2nd day after admission, the pain localized to the left lower quadrant, and a tran-
collection
Index
A. Colombo,
and
abscess were in the region ileum. No gas or additional seen within the biliary system.
perforation.
74.71
General
Hospital,
of the stones
10:1108-1110 of Radiology assembly.
U
and
Nuclear
Received
Zinkin
and
Imaging,
Rochester
accepted
October
et al
27,
1989.
Address
1 425 reprint
Portland requests
Ave.
Rochester, to
Ns’
1 462
1 . From
E.B.Z.
Volume
10
Number
6
Figure
1.
Supine
radiograph
of the abdomen.
Figure 2. CT scans of the abdomen obtained after intravenous and oral administration of contrast material.
November
1990
Zinkin
et al
U
Ra4ioGrapbics
U
1109
DIAGNOSIS: Gallstone perforation of the terminal ileum with abscess formation.
U DISCUSSION Numerous calcified gallstones may be seen in the lower abdomen, particularly the night lower quadrant. The faceted appearance of these stones, particularly when large and
multiple,
is characteristic
of gallstones
(1).
Differential diagnosis includes entemoliths, ureteral calculi, and bladder stones. Appendicoliths and entenobiths, secondary to a small bowel stricture in Crohn disease or tuberculosis, are usually solitary and, when radiopaque, will demonstrate lamellar calcifications (2) Gallstones within the gallbladden are usually more cephalic unless severe hepatomegaly, with secondary depression of the hepatic flexume of the colon, is also present. Ureteral calculi are usually associated with hydronephnosis of the kidney, as seen with CT. Bladder calculi, which might develop in a urachal remnant, would be .
smooth
and
located
bladder
and
umbilicus,
non
abdominal
between
the dome
adjacent in the might of the common
lions
ileus.”
The
ante-
1110
U
RadioGrapbics
formed, the patient rare syndrome that diagnose: recurrent U
.
Gallstone
characteristics
U
Zinkin
ileus
when
the stone
per-
is at risk of developing is even more difficult gallstone ileus (4).
is an ob-
et al
.
REFERENCES Hermanutz
D, Beta
L, Linzbach
Gallstone ileus. Radiol 12: 185-188. [German]
lower quadmanifesta-
of the classic case include mechanical small bowel obstruction (in 86% of such cases), gas in a contracted gallbladder or in the biliany ducts (60%) , and visualization of ectopic gallstones (25%) (3). The simultaneous occurrence of all three diagnostic features is name (3)
resolved
forated the terminal ileum. A transient obstruction occurred 1 day after abdominal madiography and before CT was performed. The second criterion of the syndrome, gas within the biliary system, was never observed, even on the CT scan. Stones were palpated within the gallbladder during surgical exploration. As no cholecystectomy was per-
1
Ectopic gallstones rant represent one
considered
spontaneously
a to
of the
to the
wall.
of “gallstone
vious misnomer, referring to the most frequent characteristic, small bowel obstruction. The obstruction is usually in the distal ileum due to a large stone that has eroded through the gallbladder into the duodenum or, less commonly, the stomach. This infrequent syndrome is said to account for 2%-5% of all cases of mechanical small bowel obstruction in the elderly population (1). By convention, our patient was also considered to have gallstone ileus. He presumably had a small bowel obstruction that
2.
Margulis radiology.
3.
EisenmanJl,
1983;
4.
Univ
C, Gerlack KIm
F.
1972;
AR, Burhenne HJ. Alimentary tract Vol 2. 3rd ed. St Louis: Mosby, 1655.
Finck
EJ, O’Loughlin
BJ.
stone ileus: a review of the roentgenographic findings and a report of a new roentgen AJR 1967; 101:361-366. Ulneich S, MassiJ. Recurrent gallstone AJR 1979; 133:921-923.
Volume
Gallsign. ileus.
10
Number
6
