Professional Reference articles are designed for health professionals to use. They are written by UK doctors and based on research evidence, UK and European Guidelines. You may find the Gallstones and Bile article more useful, or one of our other health articles.
Treatment of almost all medical conditions has been affected by the COVID-19 pandemic. NICE has issued rapid update guidelines in relation to many of these. This guidance is changing frequently. Please visit https://www.nice.org.uk/covid-19 to see if there is temporary guidance issued by NICE in relation to the management of this condition, which may vary from the information given below.
What is gallstone ileus?
Gallstone ileus is obstruction of the bowel due to impaction of one of more gallstones. It represents 4% of causes of bowel obstruction in the general population and 25% of obstruction occurring in the elderly. To cause an obstruction, stones usually have to be at least 2.5 cm in diameter.
In gallstone ileus, gallstones migrate through fistulas and become lodged in the gastrointestinal tract with the most common site of obstruction in the ileum (60%), followed by the jejunum (15%), stomach (15%), and colon (5%).
Stones less than 2.5 cm in diameter may traverse the alimentary canal without causing obstruction. When the gallstone lodges in the duodenum and causes gastric outlet obstruction, it is called Bouveret's syndrome.
Gallstone ileus epidemiology
- Gallstone ileus is an uncommon complication of gallstone disease, occurring in about 0.3-0.5% of all cases of gallstones.
- It accounts for only about 1-4% of causes of intestinal obstruction, but up to 25% of cases of intestinal obstruction in those over the age of 65.
- It is more common in women than in men and the incidence reflects the prevalence of gallstones with age and sex. It is regarded as 'rare and controversial'.
Gallstone ileus symptoms
The clinical presentation of gallstone ileus is frequently nonspecific with intermittent symptoms of nausea, vomiting, abdominal distension, and pain.
- Abdominal pain is an early sign with vomiting developing later. It tends to become progressively more severe.
- Abdominal pain is colicky in nature, with freedom from pain between spasms. It is periumbilical and is not clearly localised.
- Abdominal distension develops.
- Initially the patient may pass stools or flatus but not later.
- Vomiting occurs some hours after the onset of pain and it may be faeculent.
- Patients with gallstones are often, but not invariably, obese.
- The patient tends to look unwell.
- The abdomen may be bloated and small bowel peristalsis may be visible.
- Some slight and nonspecific tenderness of the abdomen is common.
- Auscultation will reveal rushes, gurgling and tinkling sounds at times of pain.
- Features of dehydration will develop.
This is between other causes of intestinal obstruction. This may include adhesions from previous surgery. Malignancy almost never occurs in the small intestine.
Colorectal cancer tends to present as chronic blood loss when proximal and obstruction when distal. This is because the contents of the bowel are liquid in the first part and become progressively more solid as they traverse the colon.
The main distinguishing features of gallstone ileus are small bowel obstruction with the presence of pneumobilia and a gallstone in the right iliac fossa on X-ray/CT (referred to as Rigler's triad).
- Plain abdominal X-ray should show the typical features of small intestinal obstruction. It may be possible to see air in the biliary tract. It may be possible to see a radio-opaque gallstone.
- Computed tomography (CT) scanning invariably demonstrates a fistulous communication, intraluminal gallstone in the small bowel, pneumobilia and any other co-existing pathology contributing to the impaction of the gallstone. The interpretation of subtle signs on CT scanning requires skill but can increase the accuracy of the diagnosis.
From the practical perspective, plain abdominal films demonstrate small bowel obstruction, ultrasound shows biliary tract pathology and CT makes the final diagnosis. Helical CT can be especially useful.
- Blood tests should include FBC, U&E and creatinine, and LFTs. As surgery is anticipated, blood should be grouped and cross-matched.
In an elderly person, routine CXR and ECG before anticipated surgery are wise.
In view of anticipated surgery, blood should be group and cross-matched.
Patients with gallstone ileus are often old and frail. Cases of gallstone ileus have been reported in patients whose intestines are strictured due to tuberculosis or other disease.
Gallstone ileus treatment and management
An intravenous infusion is required to correct dehydration and to reduce the risk of surgery. A nasogastric tube will decompress the stomach and avoid further vomiting.
Gallstone ileus is an abdominal emergency and bowel resection may sometimes be required, especially for intestinal perforation.
The procedure of choice in gallstone ileus remains controversial with possible approaches including enterolithotomy alone (has a lower morbidity and mortality rate), in conjunction with simultaneous cholecystectomy and fistula closure, or a two-stage procedure.
- Removal of the obstruction at laparotomy should be accompanied by a careful search for other gallstones proximal to the obstruction.
- The one-stage procedure should be reserved for stabilised patients. In cases with significant associated comorbidities, enterolithotomy alone may represent the best option.
- A laparoscopic technique has been shown to be effective for some patients with gallstone ileus.
Complications are common as this is major surgery, usually in a group who are old and frail.
Because the condition tends to affect the old and frail who often have comorbidities, there is a high associated mortality. Fewer procedures are associated with a lower risk of postoperative complications.
Further reading and references
Da Cunha T, Sharma B, Goldenberg S; Colonic Gallstone Ileus: Treatment Challenges. Cureus. 2021 Nov 2413(11):e19869. doi: 10.7759/cureus.19869. eCollection 2021 Nov.
Ploneda-Valencia CF, Gallo-Morales M, Rinchon C, et al; Gallstone ileus: An overview of the literature. Rev Gastroenterol Mex. 2017 Jul-Sep82(3):248-254. doi: 10.1016/j.rgmx.2016.07.006. Epub 2017 Apr 19.
Gurvits GE, Lan G; Enterolithiasis. World J Gastroenterol. 2014 Dec 2120(47):17819-29. doi: 10.3748/wjg.v20.i47.17819.
Philipose J, Khan HM, Ahmed M, et al; Bouveret's Syndrome. Cureus. 2019 Apr 911(4):e4414. doi: 10.7759/cureus.4414.
Turner AR, Sharma B, Mukherjee S; Gallstone Ileus.
Shekhda KM, Abro AH, Gupta A, et al; Gallstone Ileus. Chonnam Med J. 2021 Jan57(1):91-92. doi: 10.4068/cmj.2021.57.1.91. Epub 2021 Jan 25.
Inukai K; Gallstone ileus: a review. BMJ Open Gastroenterol. 2019 Nov 246(1):e000344. doi: 10.1136/bmjgast-2019-000344. eCollection 2019.
Bircan HY, Koc B, Ozcelik U, et al; Laparoscopic treatment of gallstone ileus. Clin Med Insights Case Rep. 2014 Aug 67:75-7. doi: 10.4137/CCRep.S16512. eCollection 2014.
Vasilescu A, Cotea E, Palaghia M, et al; Gallstone ileus: a rare cause of intestinal obstruction -- case report and literature review. Chirurgia (Bucur). 2013 Sep-Oct108(5):741-4.