Mutual influences in the development of pathology and medicine in Austria and Turkey.

The Imperial Medical School (Mektebi Tibbiye­i Sahane), established in Istanbul in 1839 as the first medical school, in the Western sense, took the Josephinum Military Medical Academy in Vienna as an example, and this led to a period of flourishing in terms of Austrian-Turkish medical relationships. Dr. Karl Ambros Bernard, Dr. Jacob Anton Neuer and pharmacist Jacob Hoffmann came to Istanbul in 1938 with the support of Prince Metternich, the Prime Minister of the Austro-Hungarian Empire at the time, and the recommendation of the private physician of the prince, a famous ophthalmologist at the University of Vienna. Subsequently, Sigmund Spitzer, who was a professor of anatomy at the University of Vienna, came to Istanbul as well. Through the efforts of Bernard and Spitzer, the new Ottoman sultan, Abdülmecid, granted authorization for the use of cadavers and autopsies for the first time in 1841, though only of Christian prisoners who had died in prison. Prof. Hyrtl, from the Medical School of Vienna, sent educational materials from his own collection for use in anatomy education. A botanist named Noe as well as Dr. Wachbicher and Prof. Lorenz Rigler also came to Istanbul. Wachbicher and Rigler worked at the school of medicine and the military hospital. This period, spanning 1839-1856, was a critical period in the Westernization of Turkish medicine. After Metternich, the Austrian government stopped sending physicians to Istanbul to assist the medical school. However, many physicians from the Austro-Hungarian Empire served in the Ottoman army until World War I. Atatürk, the founder of the modern Republic of Turkey, carried out a reform of the university system in 1933. Many scientists of Jewish origin who had escaped from Nazi oppression and many anti-Nazi German and Austrian scientists came to Turkey. An ENT professor named Erich Ruttin and a professor of radiology named Dr. Max Sgalitzer worked at Istanbul Medical School.

Clinical and radiological diagnosis of gallstone ileus: a mini review.

Gallstone ileus is a rare cause of bowel obstruction, which mainly affects the elderly population. The associated mortality is estimated to be up to 30%. The presentation of gallstone ileus is notoriously non-specific, and this often contributes to the delay in diagnosis. The diagnosis of gallstone ileus relies on a radiological approach, and herein we discuss the benefits and drawbacks of the use of different modalities of radiological imaging: plain abdominal films, computed tomography, magnetic resonance imaging, and ultrasound scanning. Based on our case experience and review of the literature, the authors conclude that although an effective first-line tool, plain abdominal films are not adequate for diagnosing gallstone ileus. In fact, the gold standard in an acutely unwell patient is computed tomography.

Modelling of the estimated contributions of different sub-watersheds and sources to phosphorous export and loading from the Dongting Lake watershed, China.

Considerable growth in the economy and population of the Dongting Lake watershed in Southern China has increased phosphorus loading to the lake and resulted in a growing risk of lake eutrophication. This study aimed to reveal the spatial pattern and sources of phosphorus export and loading from the watershed. We applied an export coefficient model and the Dillon-Rigler model to quantify contributions of different sub-watersheds and sources to the total phosphorus (TP) export and loading in 2010. Together, the upper and lower reaches of the Xiang River watershed and the Dongting Lake Area contributed 60.9% of the TP exported from the entire watershed. Livestock husbandry appeared to be the largest anthropogenic source of TP, contributing more than 50% of the TP exported from each secondary sub-watersheds. The actual TP loading to the lake in 2010 was 62.9% more than the permissible annual TP loading for compliance with the Class III water quality standard for lakes. Three primary sub-watersheds-the Dongting Lake Area, the Xiang River, and the Yuan River watersheds-contributed 91.2% of the total TP loading. As the largest contributor among all sources, livestock husbandry contributed nearly 50% of the TP loading from the Dongting Lake Area and more than 60% from each of the other primary sub-watersheds. This study provides a methodology to identify the key sources and locations of TP export and loading in large lake watersheds. The study can provide a reference for the decision-making for controlling P pollution in the Dongting Lake watershed.

Noncalcified Gallstone Ileus in Computed Tomography (CT) Abdomen and Pelvis With Contrast.

Gallstone ileus is a rare but serious complication of chronic cholecystitis, causing mechanical small bowel obstruction. Contrast-enhanced computed tomography (CT) plays a key role in radiological diagnosis. The classic findings are known as Rigler's triad, comprised of pneumobilia, small bowel obstruction, and calcified gallstones. We report a unique case of a 74-year-old female patient who presented with hallmark clinical features of bowel obstruction. CT revealed bowel obstruction and pneumobilia but did not show calcified gallstones, deviating from the usual Rigler's triad. Following midline laparotomy, a noncalcified gallstone was confirmed causing bowel obstruction. This case underscores the need to consider gallstone ileus in small bowel obstruction even in rare cases where conventional CT findings are not present, alongside the value of comprehensive radiological analysis and maintaining a high degree of clinical suspicion. Timely recognition of such atypical cases is vital for effective surgical treatment and better patient outcomes.

An authentic radiological triad of Rigler allowing the diagnosis of gallstone ileus: A case report.

The Rigler's Triad consists by three radiological signs, including intestinal obstruction, pneumobilia, and an aberrant gallstone in the bowel. It is an inconstant triad considered being pathognomonic of gallstone ileus. Gallstone ileus is an exceptional complication of cholelithiasis due to the passage of one or more gallstones from the bile ducts into the lumen of the bowel through a biliodigestive fistula. We report the case of an 83-year-old female patient with a history of ischemic heart disease and an asymptomatic large gallstone. The patient was admitted to the emergency department for bowel obstruction, abdominal pain, and bilious vomiting. A clinical examination found a patient with an alteration in general condition and a distended abdomen with tenderness. An abdominal CT scan revealed Rigler's triad, allowing the diagnosis of gallstone ileus. A midline exploratory laparotomy was performed to find a giant gallstone blocked in the last ileum loop. A simple enterolithotomy was performed, allowing the extraction of giant lithiasis from an 8-cm major axis. The postoperative evolution was uneventful, and the patient was discharged 4 days after surgical treatment.

Gallstone ileus - a well-known, but rarely encountered cause for small bowel obstruction.

Gallstone ileus is a well-known cause of small bowel obstruction in the radiological literature. In the experience of these authors, gallstone ileus occurs more often in quiz cases for registrars than in the everyday casework of a radiologist. The here presented case of a gallstone ileus provides a good opportunity to summarize cause, clinical presentation, radiological findings, and treatment options for both those studying for the specialist examinations and those whose specialist examinations are long past.

Gallstone Ileus as an Infrequent Cause of Bowel Obstruction: A Review of Small Cohort.

Introduction Gallstone ileus is an uncommon cause of small bowel obstruction; it is a rare complication of calculus chronic cholecystitis which leads to cholecystoenteric fistula and impaction of gallstone in the gastrointestinal tract leading to mechanical bowel obstruction. Our aim is to report the natural history and management of this rare condition in a teaching hospital. Materials and methods It is a retrospective study, where 10 years of data related to the management of intestinal obstruction secondary to gallstone ileus was collected. The cohort included 10 patients, whose demographic data, clinical findings, and management outcomes were evaluated. Results Majority of patients were female (90%, n=9) with a median of 83 years (range 61-96) although 90% of the population were above 70 years. Presenting complaints were mostly pain and vomiting. The onset of symptoms was between two and seven days. The site of obstruction was mostly the ileum (n=9) with the exception of one case in the sigmoid proximal to a benign stricture, and the size of the stone ranged from 2.5 to 4 cm. Moreover, most of the patients had a previous history of gallstone (n=7) with one post-cholecystectomy status. The laboratory investigations in 50% of patients had deranged liver function test (LFT) and acute kidney injury (AKI), and 60% had raised inflammatory markers, namely, white blood cells (WBC) and C-reactive protein (CRP). Intervention as enterolithotomy was the preferred approach (n=8 (two laparoscopic, six open surgery)), and two patients were managed conservatively. The mean postoperative length of stay was 10 days in the open approach and five days in the laparoscopic approach, respectively. Conclusions Elderly female patients are more prone to have gallstone ileus particularly with a past medical history of gallstones, and the preferred management option is enterolithotomy which could be open or laparoscopic depending on the expertise of the surgeon.

Mechanical Small Bowel Obstruction Due to Gallstone Ileus: Diagnostic Challenges and Surgical Management.

Gallstone ileus is a true mechanical intestinal obstruction. It is caused by gallstone impaction in the gastrointestinal (GI) tract after eroding and passing through a bilioenteric fistula. Gallstones are frequently impacted in the terminal ileum. Computed tomography (CT) imaging is diagnostic and shows specific findings of dilated small bowel loops suggesting small bowel obstruction, pneumobilia, and impacted gallstone in the small bowel. Favorable outcome is achieved by having strong clinical suspicion, timely diagnosis, preoperative resuscitation, and early surgical intervention. The three available surgical procedures to relieve gallstone ileus are entrolithotomy alone; one-stage procedure of enterolithotomy, cholecystectomy, and fistula closure; or two-stage procedure of enterolithotomy followed by cholecystectomy. This article outlines the clinical presentation, diagnosis, resuscitation, and different surgical interventions of patients with gallstone ileus.

Gallstone Ileus: Clinical Presentation and Radiological Diagnosis.

The term "gallstone ileus" refers to intestinal obstruction brought on by a gallstone lodged within its lumen. The gallstone travels through a fistula that develops because of the constant pressure it exerts on the gall bladder. The symptoms are vague and confounding which can commonly lead to delay in diagnosis. The preferred imaging technique is a computed tomography scan. The diagnosis is confirmed by the identification of Rigler's Triad on a CT scan, which includes a small intestinal obstruction, pneumobilia, and an ectopic stone in the intestine. The condition is associated with several complications and needs to be treated with emergency surgery. This case demonstrates how a patient could have non-specific symptoms and how early detection by imaging was crucial to the patient's treatment.

Gallstone Ileus Post-cholecystectomy: A Case Review.

Gallstone ileus is an unusual cause of small bowel obstruction, in general, let alone after cholecystectomy. It occurs in patients with chronic calculous cholecystitis and gallstones who develop a cholecystoduodenal fistula over time. The diagnosis is made based on clinical presentation and examination findings and is confirmed with the use of radiological modalities, such as computed tomography (CT) scan, which has been proven to be the most sensitive investigation in diagnosis. Here, we present a case of gallstone ileus that occurred 25 years after laparoscopic cholecystectomy. CT scan on admission showed adhesional small bowel obstruction given the patient's previous abdominal surgery. The patient was managed conservatively as per guidelines for the management of adhesional small bowel obstruction for 72 hours. Obstructive symptoms did not resolve despite all conservative measures, and a gastrografin challenge showed no contrast reaching the colon. Hence, the patient underwent an exploratory laparotomy to manage his ongoing bowel obstruction. Laparotomy revealed gallstone ileus as the cause of obstruction. This case highlights the importance of considering gallstone ileus in the differential diagnosis for patients who present to the emergency department with small bowel obstruction even years after cholecystectomy. Post-cholecystectomy gallstone ileus is very rare with very few cases reported in the literature. This condition poses diagnostic challenges both because of its rarity and because the gallbladder had been previously removed. A high index of suspicion by the surgeon is needed for diagnosis.

Case report: Closed-loop bowel obstruction secondary to a double gallstone ileus.

INTRODUCTION AND IMPORTANCE: In this paper, we report an unusual case of a closed-loop bowel obstruction secondary to a double gallstone ileus. This type of pathology constitutes an emergency, and requires prompt surgical intervention to prevent further complications. PRESENTATION OF CASE: The patient was a 90-year-old female who came to our emergency room with a clinical picture compatible with an acute abdomen. Imaging tests performed included a plain radiograph and abdominal CT-scan, which confirmed the diagnosis. The patient was then transferred to the operating room, and an open double enterolithotomy was performed, extracting two cylindrical gallstones with a diameter of over 2.5 cm. No treatment was given for either the gallbladder nor the biliary-enteric fistula due to the patient's physical status. CLINICAL DISCUSSION: Gallstone ileus is a rare entity, but must be taken into consideration when a patient with an abdominal obstruction arrives to the emergency department, especially when signs such as pneumobilia or visualization of the stones are detected by imaging tests. Early surgical intervention is required to avoid complications. However, addressing the biliary-enteric fistula at the same time is a sensitive procedure that may not be advisable, depending on the status of the patient. This report includes a bibliographic review of existing cases of gallstone ileus and the specifics of its diagnosis and management. CONCLUSION: This pathology can lead to serious complications if not managed properly. Prompt diagnosis and surgical intervention are essential to avoid complications such as intestinal gangrene and perforation. Inspecting the entire intestine during surgery is crucial for removing any additional gallstones that may be present to prevent the reappearance of symptoms.

Cecal Perforation by a Large Gallstone: An Unusual Diagnosis.

Cholecystocolic fistulas are uncommon, with rare cases of colonic obstruction described in the literature and even rarer cases of intestinal perforation due to gallstones. We describe a case of a 73-year-old man who presented to our ED with complaints of diffuse abdominal pain, vomiting, constipation, and fever for the past week. Abdomen CT showed signs of acute perforated appendicitis. An exploratory laparotomy was proposed which revealed cecal perforation caused by a 3 cm gallstone. A right colectomy was performed with primary anastomosis, without cholecystectomy or fistula repair. The postoperative period was complicated due to an anastomotic dehiscence on day 12 with the need for a re-laparotomy with an ileotransverse colostomy confection. The patient was in the ICU care for five days and was discharged on the 13th day after the second intervention.  The clinical presentation of gallstone ileus is nonspecific and vague often leading to a delay in the diagnosis and treatment. CT scan has the best specificity and sensibility for the diagnosis but abdominal X-ray may show the pathognomonic Rigler´s triad. The surgical treatment consists of removing the gallstone with or without simultaneous cholecystectomy and fistula repair. Reports of colonic perforation due to gallstones are very scarce, which makes this a very low suspicion diagnosis. The ideal surgical approach is not established. The morbidity of these cases can reach 50%.

Gallstone ileus with evident forchet sign:case report.

INTRODUCTION: Gallstone ileus (GSI) is a rare complication of cholelithiasis (gallbladderstone), which may lead to obstruction of the small intestine. Particularly, computerized tomographic (CT) imaging method and special findings in these images help diagnosing of gallstone ileus. Treatment of this disease is surgery, surgery involves cholecystectomy + fistula repair + enterolitotomy, but it is controversial to perform cholecystectomy with enterolitotomy and fistula repair in the same session. PRESENTATION OF CASE: A 75-year-old male patient consulted to the emergency department with the complaints of nausea and vomiting. In the examinations of the patient, bilienteric fistula and gallstones that impacted in the jejunum leading to obstruction were observed in abdominal CT images of the patient who has ileus. The patient was evaluated as gallstone ileus. In addition, on tomographic images significant Forchet sign and Rigler's triad images were viewed which were pathognomonic for gallstone ileus and did not have images as clear as in our case in the literature search. Laparotomy was performed on the patient due to the fact that he was elderly and the duration of anesthesia was wanted to be kept short and stone was extracted by enterolitotomy. Cholecystectomy and fistula repair were left for another session because of gallbladder and surrounding tissues were edematous. The patient was discharged with full recovery on the 6th post-operative day. DISCUSSION-CONCLUSION: As well as this disease is a rare cause of mechanical bowel obstruction, it is mostly seen in elderly patients. The most sensitive and specific imaging method in diagnosis is contrast-enhanced abdominal computerized tomography. In the tomographic images, especially the Rigler's triad, Forchet sign and Petren sign are pathognomonic for gallstone ileus.

Rare cause of gastric outlet obstruction.

Bouveret's syndrome is a rare cause of gastric outlet obstruction. The stones enter the small bowel via cholecysto-enteric fistula. The most common presenting symptoms are abdominal pain, nausea and vomiting. The gold standard diagnostic test isesophagogastroduodenoscopy (EGD). Rigler's triad on abdominal x-ray is classic. CT scan findings are pneumobilia, cholecystoduodenal fistula and a gallstone in the duodenum. We present a case of a 75-year-old female who presents with 3 week history of nausea, vomiting, and diffuse abdominal pain. Initial presentation, imaging and EGD was concerning for malignancy. She was later diagnosed to have Bouveret's syndrome and underwent laparoscopic small bowel enterotomy with removal of gallstones.

Pictorial review: the pearls and pitfalls of the radiological manifestations of gallstone ileus.

We present a pictorial review of a range of typical and atypical cases of gallstone ileus (GI), across a wide range of imaging modalities. GI is a complication of gallstone disease causing mechanical intestinal obstruction due to impaction of gallstone in the gastrointestinal tract. The spectrum of presentation can vary enormously, and we highlight the importance of accurate imaging diagnosis of GI especially early use of computed tomography. This will lead to timely and appropriate surgical intervention with the potential avoidance of unnecessary outcomes. The ambition of pictorial synopsis is to make the radiologists to be more vigilant to the common and more obscure imaging findings of GI.

Scenario analysis of the impacts of socioeconomic development on phosphorous export and loading from the Dongting Lake watershed, China.

Socioeconomic development in lake watersheds is closely related with lake nutrient pollution. As the second largest freshwater lake in China, the Dongting Lake has been experiencing an increase in nutrient loading and a growing risk of eutrophication. This study aimed to reveal the likely impacts of the socioeconomic development of the Dongting Lake watershed on the phosphorous pollution in the lake. We estimated the contributions from different sources and sub-watersheds to the total phosphorous (TP) export and loading from the Dongting Lake watershed under two most likely socioeconomic development scenarios. Moreover, we predicted the likely permissible and actual TP loadings to the Dongting Lake. Under both two scenarios, three secondary sub-watersheds-the upper and lower reaches of the Xiang River watershed and the Dongting Lake Area-are expected to dominate the contribution to the TP export from the Dongting Lake watershed in 2020. Three primary sub-watersheds-the Dongting Lake Area, the Xiang River, and the Yuan River watersheds-are predicted to be the major contributors to the TP loading from the entire watershed. The two scenarios are expected to have a slight difference in TP export and lake TP loading. Livestock husbandry is expected to be the predominant anthropogenic TP source in each of the sub-watersheds under both scenarios. Compared to 2010, permissible TP loading is not expected to increase but actual TP loading is predicted to grow significantly in 2020. Our study provides methodologies to identify the key sources and regions of lake nutrient loading from watersheds with complex socioeconomic context, and to reveal the potential influences of socioeconomic development on nutrient pollution in lake watersheds.

Bowel obstruction and perforation due to a large gallstone. A case report.

INTRODUCTION: Gallstone bowel obstruction is a rare form of mechanical ileus usually presenting in elderly patients, and is associated with chronic or acute cholecystitis episodes. CASE PRESENTATION: We present the case of an 80year old female with abdominal pain, inability to defecate and recurrent episodes of diarrhea for the past 8 months. CT examination uncovered a cholecystoduodenal fistula along with gas in the gall bladder and the presence of a ≥2cm gallstone inside the small bowel lumen causing obstruction. Patient was admitted to the operating room, where a 3.2cm gallstone was located in the terminal ileus. A rupture was found in the antimesenteric part of a discolored small bowel segment, approximately 60cm from the ileocaecal valve, through which the gallstone was recovered. The bowel regained its peristalsis, and the rupture was debrided and sutured. Patient was discharged uneventfully on the 6th postoperative day. DISCUSSION: Gallstone ileus is caused due to the impaction of a gallstone inside the bowel lumen. It usually passes through a fistula connecting the gallstone with the gastrointestinal tract. It can present with nonspecific or acute abdominal symptoms. CT usually confirms the diagnosis, while there are a number of treatment options; conservative, minimal invasive and surgical. Our patient was successfully relieved of the obstruction through recovery of the gallstone using open surgery, with no repair of the fistula. CONCLUSSION: Although rare, gallstones must be suspected as a possible cause of bowel obstruction, especially in elderly patients reporting biliary symptoms.

Gallstone ileus with multiple stones: Where Rigler triad meets Bouveret's syndrome.

A 53-year-old man with multiple medical conditions presented to the emergency department with complaints of vomiting, anorexia and diffuse colicky abdominal pain for 3 d. A computed tomography scan of the abdomen and pelvis showed radiographic findings consistent with Rigler triad seen in small proportion of patients with small bowel obstruction secondary to gallstone impaction. In addition there was a gastric outlet obstruction, consistent with Bouveret's syndrome. The patient underwent an exploratory laparotomy and enterotomy with multiple stones extracted. The patient had an uneventful post-surgical clinical course and was discharged home.

Pneumobilia: a case report and literature review on its surgical approaches.

Gallstones ileus is an uncommon cause but important cause of small bowel obstruction. The gallstone enters the intestinal lumen via a fistula located in the duodenum (cholecystoduodenal), or rarely, in the colon (cholecystocolonic) or stomach (cholecystogastric). This may result in large bowel or gastric outlet obstruction (Bouveret's Syndrome). Gallstone ileus affects the elderly females pre-dominantly and is associated with a high morbidity and mortality rate if diagnosis and urgent surgical intervention are delayed. In this paper, we report on the case of an elderly lady who presented with classical symptoms and signs of small bowel obstruction. She was subsequently diagnosed with gallstone ileus due to a large gallstones lodged in the intestinal lumen. We perform a literature review on this rare disease and discuss the two main surgical approaches in managing this condition. Gallstone ileus should be considered in the differential diagnosis of small bowel obstruction especially in elderly women who have no history of abdominal surgery or abdominal hernia. Early intervention is important because of the high mortality rate due to the poor general condition that often exists in this subgroup of patients. There is no general consensus on gold standard surgical approach in these cases but a two-stage procedure (either enterotomy alone or enterotomy and subsequent cholecystectomy) has been shown to be associated with lower mortality rates.