Jrebi, Nezar

Background. Gallstone ileus (GSI) is a rare form of small bowel obstruction (SBO) in patients with cholelithiasis, which is often poorly managed. Enhanced abdominal computed tomography (CT) with contrast is considered the most helpful diagnostic tool, as it is highly sensitive, specific, and accurate. We report an interesting case of recurrent GSI that was not detected by CT but diagnosed intraoperatively. Case Presentation. A 49-year-old female with a previous history of choledocholithiasis and ERCP presented to the emergency department following episodes of sudden cramping, epigastric pain, and nausea. An abdominal CT revealed evidence of SBO with clear evidence of GSI and a cholecystoduodenal fistula. Laparoscopic exploration of the small bowel revealed a large, calcified 3.5 cm × 3 cm gallstone with evidence of pressure necrosis; segmental bowel resection with stapled anastomosis was performed and patient recovered appropriately after surgery. Cholecystectomy was not performed due to multiple co-morbidities and absence of gallbladder stones. However, she presented two months later with signs and symptoms of SBO. A repeat abdominal CT showed dilated bowel with no clear transition point. This was suspected to be due to adhesions. After an initial conservative treatment which produced mild improvement, laparotomy was performed which revealed a second large non-calcified gallstone and necrotic small bowel with a pocket of abscess. Conclusion. The most sensitive diagnostic tool for GSI is enhanced abdominal CT but dilemma arises when GSI is not detected on CT. A high index of suspicion and further exploration are required in order not to miss other vital findings.

AbstractBackgroundNeuroblastomas and ganglioneuroblastomas (NB/GNB) are malignant tumors that rarely occur in adults. Their disease progression and appropriate treatment are unclear.MethodsAll adults (age ≥18 years) were evaluated for histologically confirmed NB/GNB within our institution. Data were collected via chart review and direct patient contact.ResultsFrom 1980 to 2009, a total of 15 adult patients with NB/GNB were evaluated: six men (mean age 23 years, range 19–33 years) and nine women (mean 34 years, range 20–66 years). Their overall average age at diagnosis was 30 years. Tumor‐related symptoms occurred in ten patients: Pain (abdominal 3, back 2, pelvic 1, groin 1) was more common than a mass (abdominal 2) or dysmenorrhea (1). Five patients had tumors found incidentally by computed tomography (4) or chest radiography (1). Primary tumor origins were in the pelvis (4), mediastinum (3), abdomen (2), adrenal gland (2), retroperitoneum (2), and mixed locations (2). Altogether, 12 patients underwent surgical resection (biopsy in 3; resections of R0 in 5, R1 in 3, R2 in 4). Ten underwent chemotherapy. Histology showed four GNBs and 11 NBs. Five patients with stage I disease survived a mean of 21 years (range 10–40 years). Two are alive today. Three stage III patients died at 2, 6, and 9 years after diagnosis (mean 5.7 years). Six of seven patients (one was lost to follow‐up) with initial stage IV neuroblastoma died within 5 years (mean 2.7 years). NB and GNB patients had similar survivals.ConclusionsAdult‐onset NB/GNB is rare. Symptoms appear to occur later when incurable stage IV disease is detected. Complete surgical resection can lead to long‐term, disease‐free survival in stage I patients.