A collagen-fibrin patch for the prevention of symptomatic lymphoceles after pelvic lymphadenectomy in women with gynecologic malignancies: A randomized clinical trial.

OBJECTIVE: To evaluate the efficacy of a collagen-fibrin patch for the prevention of symptomatic lymphoceles after pelvic lymphadenectomy in women with gynecologic malignancies. METHODS: In a multicenter, randomized, clinical trial, 164 women with pelvic lymphadenectomy were allocated either to bilateral pelvic application of two collagen-fibrin patches or no intervention. Main outcome was efficacy, defined as reduction of symptomatic lymphocele rate diagnosed within four weeks after surgery. Secondary outcomes were asymptomatic lymphoceles and subsequent interventions. Sample size was based on the assumption that application of a collagen-fibrin patch reduces the prevalence of symptomatic lymphoceles by at least 66%. The study was single-blinded, i.e., patients and primary outcome assessors, but not surgeons, were blinded to the treatment allocation. RESULTS: A total of 75 women were randomized to the intervention and 89 to the control group. All women received the allocated intervention. In total, 42 (27.4%) lymphoceles and 8 (5.2%) symptomatic lymphoceles were observed. Symptomatic lymphoceles were observed in 5/68 (7.4%) women in the intervention group and 3/85 (3.5%) women in the control group (p = 0.47). Asymptomatic lymphoceles were observed in 16 (23.5%) women in the intervention group compared to 18 (21.2%) in the control group (p = 0.85). In a multivariate logistic regression model, no independent risk factor for the development of a symptomatic lymphocele was ascertained. DISCUSSION: Intraoperative application of collagen-fibrin patches to the pelvic side walls does not reduce the incidence of symptomatic lymphoceles in women with gynecologic malignancies undergoing pelvic lymphadenectomy.

Criteria for Determining Malignancy in Pancreatic Intraductal Papillary Mucinous Neoplasm Based on Computed Tomography.

INTRODUCTION: Determining the dignity of intraductal papillary mucinous neoplasms (IPMNs) by imaging procedures is challenging. Various CT-based criteria were evaluated. PATIENTS AND METHODS: Preoperative CT scans from 47 patients with IPMN were analyzed. Predefined criteria of malignancy were compared between patients with benign (bIPMN; n = 28) and malignant (mIPMN; n = 19) tumors, and a summation score was determined. RESULTS: Preoperative carbohydrate-antigen 19-9 levels were higher in patients with mIPMN (p = 0.013). The diameter of the main pancreatic duct was greater in patients with mIPMN (p < 0.0001). More patients with mIPMN showed bile duct obstruction (p = 0.0076), solid tumor components (p = 0.0076), contrast enhancement in cystic walls (p = 0.0086), peripancreatic lymph nodes (p = 0.0076), and abrupt diameter changes of the main pancreatic duct (p = 0.0008). The CT density of the cysts was higher in mIPMN (p = 0.0063). The diagnostic accuracy of the summation score (sensitivity: 0.84, specificity: 0.96) was greater when compared to each individual CT parameter. CONCLUSIONS: The prevalence and extent of various CT-based abnormalities are greater in patients with mIPMN, but the wide overlap limits the diagnostic value of each individual parameter. A simple summation score largely enhances the diagnostic accuracy.

Diabetes associated with pancreatic diseases.

PURPOSE OF REVIEW: A relevant number of patients with pancreatic disorders suffer from secondary diabetes. Recent data have shed light on the link between pancreatic damage and subsequent impairments in glucose homeostasis. Furthermore, epidemiological studies provided insights into the relationship between diabetes and the risk of pancreatic carcinoma or pancreatitis. Pancreaticogenic diabetes requires a tailored therapeutic approach taking into account the individual properties of the available glucose-lowering drugs. RECENT FINDINGS: We review the available literature concerning diabetes in patients with acute or chronic pancreatitis or pancreatic carcinoma. The relationship between the pancreatic damage and alterations in insulin and glucose homeostasis is summarized as well as the effect of diabetes mellitus on the risk of pancreatic cancer and pancreatitis. Caveats in the treatment of pancreaticogenic diabetes with currently available drugs are being discussed. SUMMARY: Patients with pancreatic diseases should be screened for diabetes by means of an oral glucose tolerance test. There is a close inverse relationship between pancreatic ß-cell loss and postchallenge hyperglycemia. The risk of hypoglycemia may be increased in patients with pancreaticogenic diabetes. Newly diagnosed diabetes may be a harbinger of pancreatic cancer. There is increasing evidence suggesting an increased risk for (pancreatic) cancer and pancreatitis in patients with diabetes mellitus. Further studies on the ideal glucose-lowering treatment of patients with pancreaticogenic diabetes will be required.

P wave dispersion and QT dispersion in adult Turkish migrants with familial mediterranean fever living in Germany.

BACKGROUND: Familial Mediterranean Fever (FMF) is a hereditary autoinflammatory disease associated with subclinical inflammation, which includes atherosclerosis arising from endothelial inflammation, which in turn increases the risk of atrial or ventricular arrhythmias. Conduction abnormalities can be detected using the electrocardiographic (ECG) indices P and QT dispersion (Pdisp and QTdisp). Currently, it is unknown whether patients with FMF are more likely to have abnormalities of these ECG indices. Moreover, existing studies were conducted in countries with higher FMF prevalence. We therefore perform the first prospective study assessing Pdisp and QTdisp in adult FMF patients in Germany, where prevalence of FMF is low. METHOD: Asymptomatic FMF patients (n=30) of Turkish ancestry living in Germany and age-matched healthy controls (n=37) were prospectively assessed using 12-lead ECG. RESULTS: Patients and controls were comparable in gender and body mass index, and patients had higher erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and serum amyloid A (SAA) compared to controls (ESR: 23.7±14.3 vs. 16.1±13,3 mm/1(st)h, p=0.03, CRP: 0.73±0.9 vs. 0.26±0.4 g/dl, p=0.01, SAA: 3.14±4,8 vs. 0.37±0.3 mg/dl, p<0.01). No statistically significant difference between patients and controls respectively, for Pdisp (43.7±11.9 vs. 47.1±11.2ms, p=0.23), QTdisp (65.9±12.3 vs. 67.6±12.7 ms, p=0.58) or corrected QTdisp (cQTdisp: 73.9±15.0 vs. 76.0±13.3 ms, p=0.55) was found. No correlation could be found between Pdisp or QTdisp or cQTdisp and any of the biochemical markers of inflammation. CONCLUSION: FMF patients living in Germany show a Pdisp and QTdisp comparable to healthy controls, with no increased risk of atrial or ventricular arrhythmias indicated.

Sonographic assessment of spleen size in Turkish migrants with Familial Mediterranean fever in Germany.

OBJECTIVES: Familial Mediterranean fever (FMF) can be associated with splenomegaly. Prospective quantitative data are lacking. We performed a sonographic assessment of spleen size in patients with FMF and healthy control participants to assess its diagnostic value. METHODS: Patients with FMF according to the criteria of Livneh et al (Arthritis Rheum 1997; 40:1879-1885) who were in an asymptomatic interval and control participants were prospectively included in this study in Germany and underwent sonographic measurement of the spleen as well as a structured interview and a physical examination. Patients and controls were Turkish migrants. RESULTS: Thirty-six patients and 27 controls were included. Patients and controls did not differ significantly in age (mean ± SD, 34.8 ± 9.7 versus 33.3 ± 10.0 years, respectively; P = .56), sex, height, weight, or body mass index (26.7 ± 4.7 versus 26.1 ± 4.3 kg/m(2); P = .63). Spleen size was greater in patients than controls in width (4.3 ± 1.0 versus 3.7 ± 0.7 cm; P = .008) and also length (12.1 ± 1.9 versus 10.5 ± 1.4 cm; P = .001). Twenty-six of 36 patients (72.2%) had a history of appendectomy compared to 3 of 27 controls (11.1%; P < .001). The combination of an enlarged spleen (length >11 cm and/or width >4 cm) gave specificity of 100% (95% confidence interval, 87%-100%) and a positive predictive value of 100% (95% confidence interval, 78%-100%) for the diagnosis of FMF in our study. CONCLUSIONS: Spleen size as evaluated by sonography is larger in patients with FMF compared to healthy controls. Most patients with FMF included in this study had undergone appendectomy. Familial Mediterranean fever should be considered as a differential diagnosis in Turkish migrants in Germany if the spleen is enlarged and a history of appendectomy is reported.

Quality of life in adult patients with Familial Mediterranean fever living in Germany or Turkey compared to healthy subjects: a study evaluating the effect of disease severity and country of residence.

We assessed quality of life (QOL) and disease activity in patients with Familial Mediterranean fever (FMF) of Turkish ancestry living in Germany or Turkey and conducted a correlation with FMF disease activity. 40 FMF patients in Turkey (TR), 40 FMF patients in Germany (G) and 40 healthy controls in Germany (C) were included. QOL was evaluated with the short form of the World Health Organisation Quality of Life scale (WHOQOL-BREF). FMF disease activity was examined with the Pras score. Mean age was TR 30.5 ± 10.6, G 35.2 ± 10.2, C 34.6 ± 10.7. Of the 120 participants, 77 were female. FMF patients in TR and G had a significantly decreased QOL physical health domain compared to controls (TR 59.7 ± 18.8, G 60.4 ± 19.4, C 76.5 ± 14.6). Turkish FMF patients had a lower QOL environment domain compared to controls (TR 62.3 ± 17.5, G 69.7 ± 16.5, C 72.3 ± 13.5). In the other QOL domains, no significant differences were found. The differences in QOL were robust to a regression analysis. No significant correlation between QOL and FMF disease activity was found. German FMF patients had longer duration of disease, younger age at onset and longer delay from disease onset to colchicine treatment. A total of 5 of 40 German FMF patients were not taking colchicine (TR:0). Erythrocyte sedimentation rate was lowest in TR with significant difference between TR and G as well as G and C (TR 13.2 ± 10.3, G 27.8 ± 19.4, C 16.3 ± 12.8 mm/h). C-reactive protein did not differ between TR and G. FMF has an important impact on QOL physical health domain. No correlation between FMF disease activity and the WHOQOL-BREF could be found.

How do hospitalised patients with Turkish migration background estimate their language skills and their comprehension of medical information - a prospective cross-sectional study and comparison to native patients in Germany to assess the language barrier and the need for translation.

BACKGROUND: Today more than two million people with Turkish migration background live in Germany making them the largest ethnic minority in the country. Data concerning language skills and the perception of medical information in hospitalised patients with Turkish migration background (T) are scarce. Our study is the first to gather quantitative information on this important subject. METHODS: T and hospitalised German patients without migration background (G) of our university hospital were prospectively included into a cross-sectional study and completed a questionnaire - each group in the appropriate language (T: Turkish, G: German). RESULTS: 121 T and 121 G were included. Groups significantly differed in age (T: 44.9 ± 17.8, G: 56.9 ± 16.7y) and proportion of males (T: 37.2, G: 54.5%) but not regarding the proportion of college graduates (T: 19.3, G: 15.7%). The majority of T was born in Turkey (71%) and is of Turkish nationality (66%). 74% of T speak mainly Turkish at home; however, 73% speak German at work. 74.4% of T self-rated their German linguistic proficiency as "average" or better while 25.6% reported it as "very bad" or "bad". 10.7% of T need translation in order to pursue everyday activities. T were significantly less satisfied with the physician's information on disease and estimated to understand significantly less of what the physician told them: 46.3% of T estimated their reception of the physician's information to be "average" or worse. 43.3% of T had the impression that it would have helped them "much" or "very much" to be aided by an interpreter at the hospital. The information transmitted while giving informed consent to invasive medical procedure was judged to be "mostly" or "completely" sufficient by the majority of T (76%) and G (89.8%). In this setting 37 of 96 T (38.5%) reported being helped by an interpreter - in most cases (64.9%) a family member. CONCLUSION: Although the majority of patients with Turkish migration background have spent most of their lives in Germany (28.94 ± 10.41y) a large part of this population has limited German language skills and difficulties obtaining medical information when hospitalised.

Disease severity in adult patients of Turkish ancestry with familial mediterranean fever living in Germany or Turkey. Does the country of residence affect the course of the disease?

BACKGROUND: The environment may affect the course of familial Mediterranean fever (FMF). OBJECTIVE: The objective of this study was to compare disease severity between adult FMF patients in Turkey (TR) and Germany (G). METHODS: Adult FMF patients of Turkish ancestry on colchicine living in Turkey (n = 40) or G (n = 35) were compared. Disease severity, C-reactive protein (CRP), and erythrocyte sedimentation rate were assessed. RESULTS: Groups differed significantly in the following aspects: age at onset of disease (TR: 15.6, G: 10.8 years; P = 0.02), delay between onset and initiation of colchicine treatment (TR: 6.8 years, G: 14.9 years; P < 0.001), female gender (TR: 80%, G: 57.1%; P = 0.04), and duration of disease (TR: 14.4 years, G: 23.4 years; P < 0.001). There was no significant difference in colchicine treatment concerning average dosing and duration of therapy. No significant difference could be found between the 2 groups in CRP and disease severity as assessed by the score of Pras et al. (Am J Med Genet. 1998;75:216-219) even after adjusting for potential confounding variables. Mean erythrocyte sedimentation rate was significantly higher among patients living in G (TR: 13.2 mm/first hour, G: 26.3 mm/first hour; P < 0.001). Among patients living in Germany, there was a significant difference in age at FMF onset depending on their country of birth (born in TR: 14.9 years, born in G: 6.9 years; P = 0.0001). CONCLUSIONS: In adult FMF patients living in Turkey or Germany, no difference in disease activity or CRP could be found. German patients were younger at onset of disease and had a longer delay between onset and initiation of colchicine treatment.

Can pre-endoscopic assessment predict active upper gastrointestinal bleeding? A retrospective study in patients with symptoms of upper gastrointestinal bleeding outside regular working hours.

BACKGROUND/AIMS: To evaluate the usefulness of pre-endoscopic assessment for predicting active up-per gastrointestinal bleeding (UGI-B) at emergency esophagogastroduodenoscopy (E-EGD, within 6 hours). METHODOLOGY: We retrospectively analysed the medical records of patients that had an E-EGD performed outside working hours and considered 15 pre-endoscopic variables in a univariate analysis. Active UGI-Bat E-EGD was taken as end-point. RESULTS: Of 228 E-EGD performed during 75 months, 195 were motivated by the suspicion of UGI-B. We excluded 83 cases as they were hospitalised at the time of first symptoms of bleeding. Thus, 112 cases were included. The following clinical signs triggered E-EGD: hematemesis (56/50%),melena (55/49.1%), hematochezia (20/17.8%), anae- mia (7/6.2%). Patients' age was 65.5+14.2 years. Sixty nine (61.6%) cases were male. The relative risk and p-value of the variables for the presence of active bleeding at E-EGD were as follows: hematemesis: 1.54/0.3; malignancy and cirrhosis: 1.73/0.07; haemoglobin <8g/dL: 1.38/0.3; white blood count >12,000/tL: 1.18/0.6;systolic blood pressure (SBP) <100 mmHg: 0.53/0.03;pulse >100/min: 1.42/0.2; platelets <14000/nL:1.5/0.2; INR >1.17: 1.89/0.049. In the multivariate analysis none of these variables independently predicted UGI-B. CONCLUSIONS: No relevant pre-endoscopic variables for the prediction of active UGI-B at E-EGD could be found. Our data suggest that pre-endoscopic evaluation cannot replace rapid endoscopy.

Anxiety and depression in adult patients with familial Mediterranean fever: a study comparing patients living in Germany and Turkey.

AIM: To determine the prevalence of anxiety and depression among patients with familial Mediterranean fever (FMF) living in Germany or Turkey a prospective study was conducted. METHODS: Forty FMF patients living in Turkey (T), 40 FMF patients living in Germany (G) and 40 healthy controls living in Germany (C) were included. Patients and controls were of Turkish ancestry. G were compared to T and C. The Hospital Anxiety and Depression Scale (HADS) was used with a cut-off of ≥ 8 for each subdomain score (HADS-A, HADS-D). RESULTS: Baseline characteristics of G were comparable to T and C except for age (T: 30.5 years, G: 35.2 years, C: 34.6 years; T vs. G P = 0.045), duration of disease (T: 14.4 years, G: 24; P < 0.001), C-reactive protein (T: 0.78 mg/dL, G: 0.78 mg/dL, C: 0.35 mg/dL; G vs. C P = 0.03). Prevalence of anxiety was higher in G compared to C (T: 65%, G: 52.5%, C: 22.5%: G vs. C P < 0.05). No difference was found for the prevalence of depression (T: 30%, G: 35%, C: 20%). The association between FMF and anxiety in subjects living in Germany persisted after adjusting for age and gender in a regression analysis and was robust to an adjustment for coexisting depression. Anxiety and depression did not correlate with FMF disease severity assessed with the Pras score. CONCLUSION: Anxiety, but not depression is more common among FMF patients living in Germany compared to healthy controls. No significant difference could be found between FMF patients living in Germany or Turkey concerning the prevalence of anxiety or depression.

Effects of Treatment of Asymptomatic Hyperuricemia on Graft Survival and Mortality in Kidney Transplant Recipients.

BACKGROUND Hyperuricemia is very common after renal transplantation. It is associated with an increased risk of cardiovascular events and graft loss. To date, however, treatment is only recommended in symptomatic disease. MATERIAL AND METHODS We included 503 adult patients who underwent kidney transplantation at the Charité-Universitätsmedizin Berlin in this retrospective study. Patients were followed up for up to 120 months. All-cause mortality, graft survival, changes in level of serum uric acid (SUA), and estimated glomerular filtration rate (eGFR) were analyzed. RESULTS At 12 months post-transplantation, 225 patients had a serum uric acid (SUA) level >7 mg/dl: 52 patients were treated with allopurinol, 37 with benzbromarone, and 136 patients received no medication for hyperuricemia (control). At 12 months, eGFR did not differ between groups (p=0.15) but treated patients had higher SUA levels (p<0.001) compared to the control group. SUA-lowering treatment was associated with a lower risk of all-cause mortality (p=0.013) and graft loss (p=0.014) compared to controls. At 120 months, patients in the treatment group had lower SUA levels (p=0.001) and higher eGFR (p<0.001) compared to the control group. CONCLUSIONS Treatment of asymptomatic hyperuricemia was associated with a substantial benefit in patient and graft survival.

Correlation of Secretory Activity of Neutrophils With Genotype in Patients With Familial Mediterranean Fever.

OBJECTIVE: Familial Mediterranean fever (FMF) is an autoinflammatory disorder caused by pyrin-encoding MEFV mutations. Patients present with recurrent but self-limiting episodes of acute inflammation and often have persistent subclinical inflammation. The pathophysiology is only partially understood, but neutrophil overactivation is a hallmark of the disease. S100A12 is a neutrophil-derived proinflammatory danger signal that is strongly elevated in active FMF. This study was undertaken to characterize the secretory activity of neutrophils in vitro and investigate the association of S100A12 with disease activity and genotype in patients with FMF. METHODS: Neutrophils from FMF patients carrying the p.M694V mutation (1 compound heterozygous and 5 homozygous) and neutrophils from 4 healthy control subjects were purified and stimulated in vitro. Neutrophil secretion of S100A12, interleukin-18 (IL-18), IL-1ß, and caspase 1 was determined. Based on these in vitro analyses, serum concentrations of S100A12, IL-18, and IL-1ß were also analyzed in 128 clinically and genetically characterized patients with FMF. RESULTS: In vitro, unstimulated neutrophils from p.M694V-positive patients spontaneously secreted more S100A12, IL-18, and caspase 1 compared to neutrophils from healthy controls. Serum concentrations of S100A12 correlated with disease activity and genotype, with the levels being highest in homozygous patients and with compound heterozygotes displaying higher levels than heterozygotes. Compared to individuals negative for the p.M694V mutation, heterozygous, compound heterozygous, or homozygous p.M694V-positive patients had higher serum levels of S100A12 and IL-18 during inactive and subclinical disease. CONCLUSION: The FMF phenotype is known to be more severe in patients carrying the p.M694V mutation. This report describes 2 molecules secreted by unconventional secretory pathways, S100A12 and IL-18, whose concentrations correlated with clinical disease activity and genotype in patients with FMF. In this clinically and genetically heterogeneous disease, management of these surrogate markers might help to improve patient care and outcomes.

[How do Turkish immigrants evaluate cultural sensitivity in a German tertiary hospital?]. / Wie schätzen stationäre Patienten mit türkischem Migrationshintergrund die Kultursensibilität in einem deutschen Krankenhaus der Maximalversorgung ein?

BACKGROUND: Culturally adequate medical care is a goal in Germany, but quantitative data concerning inpatients is lacking. METHODS: Inpatients of a German tertiary hospital: Turkish migrants (T) and Germans (G) were interviewed in their respective native language. RESULTS: 121 T and 121 G were interviewed. 97.5% of T were Muslims, 82.6% of G were Christians. 88.5% of T judged religion as "important" or "very important" (G: 35.8%). 50.8% of T saw their opportunity to pray in the hospital as "bad" or "very bad" (G: 0.9%). Keeping to Islamic dietary rules in the hospital was "difficult" or "very difficult" for 90% of T. For 79.0% of female T care by a same-sex staff was "important" or "very important" (female G: 36.3%, male T: 40.0%, male G: 7.7%). The presence of a same-sex person during examinations or treatments was "much" or "very much" appreciated by 69.7% of female T, if same-sex care was impossible (female G: 25.4%, male T: 28.9%, male G: 6.1%). A retrospective analysis revealed that 5.8% of all 8988 hospital admissions during the period of study recruitment were Turkish migrants. CONCLUSION: To meet the needs of Turkish migrants German hospitals should improve the opportunity for Muslims to pray. Additionally, the cooperation with local imams should be sought. Precise descriptions of food ingredients or an adapted menu could help T to deal with Muslim dietary commandments. A culturally sensitive hospital should take into account that female as well as male T prefer to be cared of by same-sex physicians and nurses.

Postponing elective hospitalizations for pre-admission MRSA screening and decolonization. A study evaluating eligibility and acceptance among patients of a German university hospital.

There is evidence that pre-admission screening and decolonization (PreASD) of MRSA can reduce costs in elective surgical patients. It is not known whether this strategy could also be successfully applied to general medical patients of a tertiary referral hospital with multiple specialties. Our study retrospectively evaluates the eligibility of patients for MRSA-PreASD in a setting of active targeted MRSA surveillance. We carried out a survey among eligible patients to assess acceptance and feasibility of MRSA-PreASD. Of 10,496 admissions to our university hospital 8912 (84.9%) were screened for MRSA-risk factors. In 5382 admissions at risk swabs were taken and analyzed. Using the Appropriateness Evaluation Protocol (AEP) we retrospectively assessed how many of the 5382 admissions at risk could have been postponed for the duration of an MRSA-PreASD. 36 (17%) of 212 admissions with proven MRSA colonization and 2175 (42%) of 5170 patients without detectable MRSA could have been sent home for MRSA-PreASD to be electively admitted later. Of the 36 admissions (35 patients) with proven MRSA eligible for PreASD 23 patients (65%) responded to an interview. 22 of those (95.6%) would have agreed to PreASD. Additional costs for a screening protocol adapted to the needs of MRSA-PreASD of 52,061€ were estimated. Additional hospitalization costs of 6100-9300€ per MRSA case in Germany have been published. In our study population the successful pre-admission decolonization of 22 cases (63% of 35 patients eligible) may therefore have saved about 134,000-205,000€. Thus from an economic point of view our concept should be justified. In conclusion a relevant number of affected admissions to our tertiary referral hospital is eligible for an MRSA-PreASD. The majority of patients with proven MRSA-colonization eligible for a pre-admission decolonization treatment would prefer such an approach over being isolated at the hospital. The implementation of an MRSA-PreASD-protocol may reduce costs.

Development of a duodenal gallstone ileus with gastric outlet obstruction (Bouveret syndrome) four months after successful treatment of symptomatic gallstone disease with cholecystitis and cholangitis: a case report.

INTRODUCTION: Cases of gallstone ileus account for 1% to 4% of all instances of mechanical bowel obstruction. The majority of obstructing gallstones are located in the terminal ileum. Less than 10% of impacted gallstones are located in the duodenum. A gastric outlet obstruction secondary to a gallstone ileus is known as Bouveret syndrome. Gallstones usually enter the bowel through a biliary enteral fistula. Little is known about the formation of such fistulae in the course of gallstone disease. CASE PRESENTATION: We report the case of a 72-year-old Caucasian woman born in Germany with a gastric outlet obstruction due to a gallstone ileus (Bouveret syndrome), with a large gallstone impacted in the third part of the duodenum. Diagnostic investigations of our patient included plain abdominal films, gastroscopy and abdominal computed tomography, which showed a biliary enteric fistula between the gallbladder and the duodenal bulb. Our patient was successfully treated by laparotomy, duodenotomy, extraction of the stone, cholecystectomy, and resection of the fistula in a one-stage surgical approach. Histopathological examination showed chronic and acute cholecystitis, with perforated ulceration of the duodenal wall and acute purulent inflammation of the surrounding fatty tissue. Four months prior to developing a gallstone ileus our patient had been hospitalized for cholecystitis, a large gallstone in the gallbladder, cholangitis and a small obstructing gallstone in the common biliary duct. She had been treated with endoscopic retrograde cholangiopancreatography, endoscopic biliary sphincterotomy, balloon extraction of the common biliary duct gallstone, and intravenous antibiotics. At the time of her first presentation, abdominal ultrasound and endoscopic examination (including esophagogastroduodenoscopy and endoscopic retrograde cholangiopancreatography) had not shown any evidence of a biliary enteral fistula. In the four months preceding the gallstone ileus our patient had been asymptomatic. CONCLUSION: In patients known to have gallstone disease presenting with symptoms of ileus, the differential diagnosis of a gallstone ileus should be considered even in the absence of preceding symptoms related to the gallbladder disease. Gallstones large enough to cause intestinal obstruction usually enter the bowel by a biliary enteral fistula. During the formation of such a fistula, patients can be asymptomatic.