Year : 2007 | Volume
: 13 | Issue : 1 | Page : 39--42
Gallstone Ileus: A forgotten rare cause of intestinal obstruction
Department of Surgery, College of Medicine and King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
King Khalid University Hospital, Department of Surgery, P. O. Box 7805 (37), Riyadh 11472
Gallstone ileus is an uncommon complication of cholelithiasis, with a high morbidity and mortality rate - usually related to the delayed diagnosis of intestinal obstruction. Diagnosing gallstone ileus needs a high index of suspicion. A case of a gallstone ileus is reported. The clinical presentation, radiological features, intraoperative findings, operative procedure and literature review are presented.
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Al-Obaid O. Gallstone Ileus: A forgotten rare cause of intestinal obstruction.Saudi J Gastroenterol 2007;13:39-42
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Al-Obaid O. Gallstone Ileus: A forgotten rare cause of intestinal obstruction. Saudi J Gastroenterol [serial online] 2007 [cited 2021 Jan 28 ];13:39-42
Available from: https://www.saudijgastro.com/text.asp?2007/13/1/39/30465
Gallstone ileus is an uncommon complication of cholelithiasis, with a high morbidity and mortality rate.
Pavlidis et al. retrospectively reviewed nine cases of gallstone ileus over a period of 11 years at their Center. They found that it constituted 0.4% of all cholecystectomies (9 out of 2,242) and 3.7% of the 243 operated small bowel obstructions.
Reisner and Cohen retrospectively analyzed 1,001 cases reported from 1953 to 1993 in the English language literature. They point out that gallstones cause 1-3% of all intestinal obstructions and 25% of nonstrangulated small bowel obstructions in patients over the age of 65. The female-to-male ratio was 3.5:1, and the age range was 13-97 years (average 72 years).
A 68-year-old male presented to the emergency room with a 3-week history of intermittent abdominal pain, decreased bowel movement, vomiting and abdominal distention. Two days prior to admission, the abdominal pain became worse, and the patient developed an absolute austipation. His past medical history was unremarkable except for a laparotomy for trauma.
On examination, he was slightly tachycardic (94/min) and afebrile; his BP was 118/73; his abdomen was soft, distended and slightly tender.
WBC was 11.8, LFTs were normal. Abdominal X-ray showed distended small bowel loops with multiple air-fluid levels [Figure 1]. CT scan showed distended small bowel loops, stone impacted at the terminal ileum near the ileocecal junction and pneumobilia [Figure 2],[Figure 3].
The patient was resuscitated with fluids, and a nasogastric tube was inserted. Thereafter, he was taken to the operating room. In the operating room, a midline incision was made; the stone was identified at the ileocecal junction and was milked to the jejunum, where an enterotomy was made and the stone was extracted. The enterotomy was then closed in two layers. The stone was 26 mm x 23 mm in size [Figure 4]. The bowel was runed and checked for the possibility of other stones. Postoperatively, the patient did well and was discharged home 10 days post-surgery.
Reisner and Cohen point out that correct diagnosis of gallstone ileus, confirmed at laparotomy, was made preoperatively in 43% of the patients in the collected series.
Traditionally, plain abdominal radiography remained a mainstay for the assessment of small bowel obstruction. However, the sensitivity of plain film varies from 40 to 70% in diagnosing gallstone ileus. The classical radiological features of gallstone ileus were described by Rigler et al. in 1941 and are summarized in [Table 1].
Ultrasonography has been shown to be more helpful than plain films in diagnosing gallstone ileus. But the sensitivity of detection rate in a large-scale US study was 74% at best., Lassandro et al. retrospectively compared the clinical value of plain abdominal film, abdominal sonography and abdominal CT in diagnosing gallstone ileus in 27 patients. They found that abdominal sonography demonstrated bowel loop dilatation (44.44%), extraluminal fluid (14.81%), ectopic stones (14.81%), gallbladder abnormalities (37.04%), pneumobilia (55.56%).
Several case reports have examined the accuracy of CT in the diagnosis of gallstone ileus. Chih-Yung et al. retrospectively established the diagnostic criteria for gallstone ileus on CT, and they prospectively applied these criteria to determine the diagnostic accuracy of CT to diagnose gallstone ileus in patients who presented with acute small bowel obstruction (SBO). In this study, 14 CT scans in cases of proved gallstone ileus were evaluated retrospectively by two radiologists for the presence or absence of previously reported CT findings to establish the diagnostic criteria.
These criteria were applied in a prospective contrast-enhanced CT study of 165 patients with acute SBO; this included those 14 cases of gallstone ileus. The overall sensitivity, specificity and accuracy of CT in diagnosing gallstone ileus were 93, 100 and 99% respectively. Based on their study, the diagnostic CT criteria include SBO, ectopic gallstone, rim-calcified or total-calcified, abnormal gall bladder with complete air collection, presence of air-fluid level or fluid accumulation with irregular wall.
The site of stone impaction as shown by Reisner and Cohen review is:
Ileum 60.5%Jejunum 16.1%Stomach 14.2%Colon 4.1%Duodenum 3.5%Passed spontaneously 1.3%
Lassandro et al. retrospectively reviewed 40 charts of consecutive patients with a proven surgical diagnosis of gallstone ileus; all the patients had undergone CT before surgery. Intestinal obstructions were detected in 32 patients, pneumobilia in 35 and air in the gallbladder in 6. Direct visualization of a biliary-enteric fistula was noted in 5 patients. Correct location of the stone was made in 35 patients at the first report; in 5 patients with partially calcified stone (12.5%), a retrospective review of the imaging findings (bulging of the intestinal loop or endoluminal calcifications) suggested their locations. Multiple stones were found in 5 patients. Diameter of the stones varied from 0.6 to 3.5 cm; the smallest impacted stone had a maximum diameter of 2.5 cm and the largest, 3.5 cm.
The appropriate treatment of gallstone ileus is controversial. Both operative and nonoperative approaches have been described in the literature.
Eighty percent of the 1,001 patients in the collected series of Reisner and Cohen had enterotomy and stone extraction, 11% (113 patients) had a 1-stage operation that included enterotomy and stone extraction with either cholecystectomy or cholecystestomy and/or takedown of the fistula, 4% of the patients had a diverting colostomy and 5% were treated conservatively. The morbidity and mortality from gallstone ileus in that series are shown in [Table 2],[Table 3].
Pavlidis et al. operated on nine patients with gallstone ileus. The operation included enterolithotomy alone (three high-risk cases) or enterolithotomy plus fistula repair and cholecystectomy (six cases). There were three postoperative complications, including wound dehiscence, wound infection and obstructive jaundice (morbidity, 37.5%); and one death due to myocardial infarction (mortality, 11%). They concluded that a one-stage procedure (enterolithotomy plus fistula repair and cholecystectomy), when feasible, should be the first choice.
The higher mortality associated with one-stage operation, although not statistically significant, warranted a procedure directed at the obstruction. Moreover, the morbidity related to the biliary tract and the biliary-enteric fistula is low [Table 3]. Even a subsequent cholecystectomy might not be needed if the patient is a symptomatic. In the case that we reported, the decision was made not to perform a cholecystectomy because the patient was asymptomatic 2 months after the operation and the ultrasound showed a normal biliary tree.
Recently, lithotripsy has been used successfully to break up an obstructing gallstone. Sackmann et al. treated successfully a 71-year-old female patient with a gallstone obstructing the jejunum. They used an electrohydraulic lithotripter - 1,600 discharges at mean discharge energy of 25,000 V directed toward the stone under ultrasound guidance. The stone disintegrated after one session, and the stone fragments were identified in the feces. The patient's recovery was uneventful. Several reports have described a successful stone fragmentation using lithotripsy, either transabdominal or transluminal using an endoscope.
The laparoscopy-assisted techniques have been reported in the management of gallstone ileus. Sarli et al. successfully treated three women with gallstone ileus via the laparoscopy-assisted technique. All three patients have made fast and uneventful recovery. The procedure was accomplished in less than 1 h in every patient. Preoperative diagnosis was made in one patient and intraoperative in the other two patients. Several authors have reported a successful laparoscopy-assisted enterolithotomy in patients with gallstone ileus. However, one should remember that laparoscopy is somehow more challenging in those patients because of the dilated and edematous bowel in those cases that require gentle manipulation of the bowel to prevent perforation. Also, one should remember that incidence of second stone has been reported in 3-15% of patients, and the need to run the bowel either by the laparoscope or through a mini laparotomy is important.
The final technical issues to remember are milking the stone and making the enterotomy away from the site of impaction because it is often edematous. In addition, resection of the segment of bowel might be necessary if the stone is firmly fixed in an edematous and inflamed segment of bowel.
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