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.