In the main the treatment is surgical. Urgent surgery is not usually
required as the patient does not have peritonitis. This gives more time
for assessment of the patient and optimisation of their medical
co-morbidities and correction of their fluid and electrolyte derangement
prior to definitive treatment, hopefully increasing the chances of a
favourable outcome. A full history and clinical examination should be
performed with special reference to the presence of significant medical
co-morbidities, drug therapy, allergies and state of hydration. A
careful examination of the abdomen to check for evidence of hernia and
tenderness signifying peritonitis is mandatory.
The patient should have their blood count, urea and electrolytes and
creatine measured, they should have a CXR and an ECG. Blood should be taken for
group and hold. The patient should be reassured and an NG tube placed to
prevent vomiting. It would be wise to pass a urethral catheter and monitor the
urinary output. Fluid resuscitation should be instituted based upon an
assessment of the patient's fluid deficit, their base line requirement, their
on-going losses and their response to therapy. Most of these patients are
quite dehydrated and need re-expansion of their extracellular fluid compartment
with fluid that will replenish this compartment (eg. Normal Saline or Hartmans
solution).
Prophylactic treatment with low molecular weight heparin should be
commenced, the patient should be fitted with TED stocking unless
contraindicated. Similarly consideration should be given to the need for stress
ulcer prophylaxis. Antibiotic prophylaxis may be held until the patient has
gone to the operating room. The patient (and the patients family if the
patient wishes) should be informed about the planned operation and advised
about the risks and alternatives so that consent may be obtained.
When the patient has been re-hydrated and optimised as far as possible
definitive surgery may be performed, this usually requires a laparotomy with a
small enterotomy and retrieval of the stone. Following this the enterotomy is
repaired and the abdomen closed.
The enterotomy is made in the healthy proximal small bowel and the stone
milked back. It is best to make a longitudinal incision and then close
this transversely to avoid narrowing.
It is not necessary to try and repair the bilio-enteric fistula.
Rushing the patient to theatre is bound to result in an unhappy outcome.
Patients should receive treatment prior to theatre to improve their
condition.
Dissolution therapy is of historical interest for the treatment of
gallstones. It would not work in gall stone ileus.
ERCP may be of some use if there is a gallstone impacted in the lower
end of the bile duct, or perhaps to treat a stricture of the bile duct
but it would only subject the patient to needless risk for no benefit in
the present situation.
Shock wave lithotripsy is mainly of benefit in patients with renal
stones. It has been tried in gall stones but is not very good.
