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Gallstone ileus is obstruction of the bowel due to impaction of one of more gallstones. To achieve this, 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 is an uncommon complication of gallstone disease, occurring in about 0.5% of cases.
- 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'.
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.
- 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.
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, 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.
- One retrospective study concluded that treatment should be individualised and that removal of the stone through the bowel (enterolithotomy) should only be accompanied by cholecystectomy if the patient has good cardiorespiratory reserve and with absolute indications for biliary surgery at the time of presentation (the one-stage procedure).
- 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, there is a 20% mortality. There appears to be no real difference in terms of the operative procedure performed - eg, simple enterolithotomy to fistula repair.
Further reading and references
Gurvits GE, Lan G; Enterolithiasis. World J Gastroenterol. 2014 Dec 2120(47):17819-29. doi: 10.3748/wjg.v20.i47.17819.
Farooq A, Memon B, Memon MA; Resolution of gallstone ileus with spontaneous evacuation of gallstone. Emerg Radiol. 2007 Nov14(6):421-3. Epub 2007 May 31.
Qamrul Arfin SM, Haqqi SA, Shaikh H, et al; Bouveret's syndrome: successful endoscopic treatment of gastric outlet obstruction caused by an impacted gallstone. J Coll Physicians Surg Pak. 2012 Mar22(3):174-5. doi: 02.2012/JCPSP.174175.
Farrell I, Turner P; A simple case of gallstone ileus? J Surg Case Rep. 2015 Jan 142015(1). pii: rju148. doi: 10.1093/jscr/rju148.
Ravikumar R, Williams JG; The operative management of gallstone ileus. Ann R Coll Surg Engl. 2010 May92(4):279-81.
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.
Gan S, Roy-Choudhury S, Agrawal S, et al; More than meets the eye: subtle but important CT findings in Bouveret's syndrome. AJR Am J Roentgenol. 2008 Jul191(1):182-5.
Ayantunde AA, Agrawal A; Gallstone ileus: diagnosis and management. World J Surg. 2007 Jun31(6):1292-7. Epub 2007 Apr 15.
Lassandro F, Romano S, Ragozzino A, et al; Role of helical CT in diagnosis of gallstone ileus and related conditions. AJR Am J Roentgenol. 2005 Nov185(5):1159-65.
Iqbal T, Tahir F, Khan A, et al; Gall-stone ileus with multiple tuberculous strictures. J Coll Physicians Surg Pak. 2008 Jan18(1):45-7.
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.
Brezean I, Aldoescu S, Catrina E, et al; Gallstone ileus: analysis of eight cases and review of the literature. Chirurgia (Bucur). 2010 May-Jun105(3):355-9.