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The fluoroquinolone class of antibiotics represents a convenient oral group 316 Current Essentials of Surgery Cholelithiasis, Rare Complications s Essentials of Diagnosis Gallstone ileus: small bowel obstruction secondary to 1 or more large gallstones entering via cholecystoduodenal fistula Mirizzi syndrome: biliary stricture secondary to direct compres- sion by chronically impacted cystic duct gallstone or chronically inflamed gallbladder Epidemiology: both gallstone ileus and Mirizzi syndrome are rare, mainly affecting patients 60 years Imaging findings in gallstone ileus: abdominal x-ray shows air- fluid levels, dilated loops of small bowel, possible pneumobilia; ultrasound shows cholelithiasis and pneumobilia; swallow study with water-soluble contrast shows fistula between duodenum and gallbladder Imaging findings in Mirizzi syndrome: ultrasound shows biliary dilatation (6 mm), cholelithiasis, possible thickened wall of gallbladder Workup: for gallstone ileus, obtain plain abdominal x-ray, right upper quadrant ultrasound, small bowel contrast study if partial small bowel obstruction; for Mirizzi syndrome, perform liver function tests, right upper quadrant ultrasound s Differential Diagnosis Cholecystitis, choledocholithiasis, choledochal cyst Hepatitis Pancreatitis Adhesive bowel obstruction s Treatment Gallstone ileus: remove retained small bowel gallstone(s) via enterostomy or partial resection if bowel is ischemic; perform cholecystectomy and resection of fistula plus duodenal closure at same operation or as staged procedure Mirizzi syndrome: perform cholecystectomy and resection or bypass of stricture via hepaticojejunostomy s Pearl These rare complications are more common in elderly patients.

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