Discussion:
Small intestin perforations are considered rare, unlike gastroduodenal and colonic perforations [1]. The spectrum of etiology of perforation in tropical countries is different from its western counterpart. In contrast to western countries where lower gastro-intestinal tract perforations predominate, upper gastro intestinal tract perforations constitute the majority of cases in developed countries [2]. The following are the main causes of perforation: ischemic, occlusive, inflammatory (Meckel’s diverticulitis), infectious (tuberculosis, typhoid fever), or traumatic (instrumentation, foreign body…) [1]. Although infectious causes, especially typhoid and tubercu­losis are forefront in developing countries, Crohn’s disease and malignancies are more common in de­veloped countries [3]. Rare causes of perforation include lymphoma, malignant small intestin tumor, Crohn’s disease and internal hernia, which account to only 5.4% according to the retrospective study of a Turkish team aiming to track down all causes of small bowel perforation [4]. Gallstones were not covered by this inventory, thus leading us to publish this case.
Among the infrequent complications that can be observed in the evolution of cholelithiasis is biliary ileus; it is in the path of vesicular macrocalculi that exert spontaneously resolving acute cholecystitis attacks. Over time the vesicular wall thickens due to the parietal inflammatory modulation with accentuation of fibrosis. During this transformation, it can attract an adhesion with the neighboring structures, in particular the duodenum, due to its favorable anatomical position. The impact of the stone generates a localized pressure necrosis up to the parietal ulceration and then perforation, thus allowing the stone to be delivered into the digestive lumen to discharge the calculus into the digestive tract. The calculus will follow the peristaltic activity along its course it could be impacted against the anatomical stricture zones generating the occlusion but the intestinal perforation is a rare event. This case illustrates this rarest eventuality. Perforation generally occurs in the antimesenteric border. This is explained by its poor blood supply, making it more susceptible to pressure necrosis from gallbladder stones [5]. Peritonitis arises from intestinal contents smeared out of the perforation.
The management covers the fundamental and elementary gestures: aspiration of pus, retrograde emptying of the small intestine, peritoneal cleansing with warm saline and removal of loose fibrin. The operative challenge resides in the handling of the perforation and the causative fistula. Intestinal sutures are avoided and intestinal bypass is necessary with a resection extension of 10 centimeters on both sides of the perforations, because the ulceration of the mucosa and of the surrounding submucosa is almost constant [6]. Anastomosis failure is more likely in case of documentation of shock at presentation, the presence of two or more perforations, and intraoperative contaminant volume of more than one litre, the choice of ileostomy over resection/anastomosis is then the keystone of surgical treatment [7]. We advocate resection because it additionally provides insight into the cause of the perforation, whose therapeutic pursuit is steered by the histological result. The association of a biliary gesture or its execution in a second operative course increases the morbidity and remains for most of the authors useless in the absence of ulterior symptoms since the fistula ceases spontaneously in more than 50% of cases. The recurrence rate is minimal (less than 5%) [8]. By taking this information into consideration, we agreed to suspend the biliary procedure and shorten the operative time. The latest operative step must be devoted to examine the small intestin thoroughly for the presence of other intraluminal stones.