We reported two cases of gallstone ileus, a relatively rare complication of cholelithiasis. Case 1 was a 78-year-old woman who presented with 3-day history of vomiting. Computed tomography (CT) scan showed emphysema of the intrahepatic bile duct, a lithoid foreign body in the small intestine, and adoral intestinal dilatation. Thus, gallstone ileus was diagnosed. Case 2 was a 71-year-old woman who presented with 2-day history of nausea and vomiting. CT scan showed no gallstone, but emphysema of the gallbladder, a lithoid foreign body in the small intestine, and adoral intestinal dilatation, which indicated gallstone ileus. The both cases were accompanied by renal dysfunction due to dehydration. As retained calculus was not found in the gallbladder, we performed surgery only for dissolution of ileus with removal of the calculus through a small incision on the intestine. The postoperative course was good in both patients. For gallstone ileus, decision of surgery, stone removal with or without cholecystectomy, should be based on the patient’s status, retained gallstones and persistent fistula. We herein discuss on the surgical treatment for gallstone ileus with an analysis of the 52 reported cases for the past 5 years in Japan.

Aim This paper aims to assess teachers’ and school nurses’ awareness of Epinephrine auto-injectors and approaches to improve their first-aid skills in the use of these injectors in Japanese schools.
Methods Igaku Chuo Zasshi and Citation Information by NII were searched using the search formula (School) AND (EpiPen) in Japanese-language articles. The followings were the inclusion criteria: Japanese literature; subjects were teachers or school nurses; investigated awareness of Epinephrine auto-injectors or reported an approach for improving first-aid use of Epinephrine auto-injectors. Review articles were excluded.
　 Eligible articles were analysed according to (a) awareness of Epinephrine auto-injectors and (b) approach.
Results Of the 145 articles, 13 met the inclusion criteria. Six articles investigated teachers’ and school nurses’ awareness of Epinephrine auto-injectors or Epinephrine auto-injector. Eight articles reported educational approaches to training and school nurses. Of 13 eligible articles, 1 article reported both teacher’ and school nurses’ awareness, and educational approaches. In awareness articles, almost all teachers and school nurses knew about Epinephrine auto-injector; however, several schoolteachers or school nurses did not know whether children using Epinephrine auto-injector attended their school. Many teachers and school nurses had anxiety about their ability to appropriately deliver an Epinephrine auto-injector injection, their ability to detect anaphylaxis symptoms, when to inject Epinephrine auto-injector and how to use Epinephrine auto-injector.
　 In almost all lectures described in these educational approach reports, medical doctors and nurses who worked in paediatric hospitals lectured about food allergies, anaphylaxis symptoms and how to use Epinephrine auto-injector. The lectures included a lecture component and a practice component. These lectures improved the understanding and first-aid skills of teachers regarding symptoms, treatment and how and when to deliver an Epinephrine auto-injector injection, and built confidence or relieved anxiety about the appropriate use of Epinephrine auto-injector. Of the 8 articles, only 1 had a before-and-after methods evaluation. None of the studies introduced a comparison group.
Conclusion Teachers and school nurses working in Japanese schools attended by children prescribed with an Epinephrine auto-injector need to understand allergic and anaphylaxis symptoms, as well as how and when to deliver an Epinephrine auto-injector injection. The need to understand and have the skill to use allergy and Epinephrine auto-injectors may be satisfied with a lecture and practice course. Further studies are needed, with before-and-after comparisons, objective tools checking teachers’ understanding or performance, and a comparison group for evaluating whether the lecture adequately covered the proper use of Epinephrine auto-injectors in real-world situations where anaphylaxis occurs.