International Journal of Gerontology | March 2008 | Vol 2 | No 1 18

CASE REPORT
2008 Elsevier.
Introduction
Gallstone ileus is an uncommon cause of small bowel
obstruction, accounting for only 14% of all causes of
intestinal obstruction. In patients with cholelithiasis,
only 0.30.5% develop gallstone ileus. However, in
patients over the age of 65, gallstone causes 25% of
non-strangulated small bowel obstructions
1,2
. The mor-
bidity and mortality are high if the diagnosis is missed.
The mortality reportedly ranges from 1218%, parti-
cularly in older patients who often have comorbid
illnesses that increase the operative risk
3
.
Case Report
A 78-year-old male was admitted with severe vomiting,
abdominal distention, and a fever with a temperature
to 39.5C for 1 day. The vomitus was yellow-green
without coffee ground material or blood. He had passed
no stool in the 2 days prior to admission. The patient
was known for some time to have asymptomatic gall-
stones. He had chronic lung disease and had had a
productive cough for 1 month prior to admission. In
addition, he had diabetes and a history of brain trauma
requiring a ventriculoperitoneal shunt.
An initial chest X-ray showed a right lower lung
infiltrate, and an abdominal plain film showed a ven-
triculoperitoneal shunt in situ and a 32cm gallstone
in the right upper quadrant. The bowel gas was non-
specifically increased (Figure 1A). His white cell count
was 20,500/L, hemoglobin 16.4g/dL and blood sugar
211mg/dL. The levels of bilirubin and liver enzymes
were not elevated. The admitting diagnosis was pneu-
monia, and the vomiting was thought to be attributed
to the infection. However, the vomiting became worse
after admission. A repeat plain abdominal film showed
severely distended bowel loops and migration of the
gallstone to the right lower quadrant (Figure 1B).
Abdominal ultrasound also showed a gallstone in the
right lower quadrant (Figure 2). We consulted a surgeon
for management of apparent gallstone ileus, but the
patients symptoms suddenly improved and further
GALLSTONE ILEUS: A DISEASE EASILY
IGNORED IN THE ELDERLY
Chen-Wang Chang
1,2
, Shou-Chuan Shih
1,2
, Shee-Chan Lin
1,2
, Cheng-Hsin Chu
1,2
,
Tsang-En Wang
1,2
, Wen-Hsiung Chang
1,2
*
1
Division of Gastroenterology, Department of Internal Medicine, Mackay Memorial Hospital,
and
2
Mackay Medicine, Nursing and Management College, Taipei, Taiwan.
SUMMARY
Gallstone ileus is an uncommon cause of small bowel obstruction, accounting for only 14% of all intestinal
obstructions. In patients with cholelithiasis, only 0.30.5% reportedly develop gallstone ileus. However, the
condition causes 25% of cases of non-strangulated small bowel obstruction in those over the age of 65 years.
We report a patient with gallstone ileus who presented with small bowel obstruction that was initially misdiag-
nosed. The correct diagnosis was made based on finding an ectopic gallstone on plain abdominal radiography,
a cholecystoduodenal fistula, and gallstone impaction in a small bowel follow-through study. [International
Journal of Gerontology 2008; 2(1): 1821]
Key Words: elderly, gallstone, ileus
*Correspondence to: Dr Wen-Hsiung Chang, Division
of Gastroenterology, Department of Internal
Medicine, Mackay Memorial Hospital, 92, Section 2,
Chung-Shan North Road, Taipei, Taiwan.
E-mail: mmh13@ms1.mmh.org.tw
Accepted: September 10, 2007
International Journal of Gerontology | March 2008 | Vol 2 | No 1 19

Gallstones Ileus
imaging studies and observation were recommended.
A small bowel barium enema demonstrated a gallstone
apparently impacted in the distal ileum and dilated
proximal loops of bowel. An enterobiliary fistula was
also suspected (Figure 3). An abdominal computed
tomography (CT) confirmed these findings (Figure 4),
and the patient underwent enterorrhaphy with removal
of the gallstone. He recovered from surgery uneventfully.
Discussion
The classic radiographic triad for gallstone ileus,
Riglers triad, includes signs of small bowel obstruction,
pneumobilia, and ectopic gallstone
4
. Our patients ini-
tial plain film was not particularly suggestive of this
diagnosis, as the gallstone was seen in the right upper
quadrant. There was no way of telling if it was within
the gall bladder or already in the bowel. Also, the
bowel loops were not particularly distended at that
point in his course. In fact, only 914% of patients
have a clear-cut Riglers triad
4,5
. Our patients persistent
symptoms were adequate indication for repeat radiog-
raphy, which by then did show both dilated bowel loops
and an ectopic gallstone.
The sudden relief of the patients symptoms at the
time of the first surgery consultation is not at all unusual.
Symptoms of gallstone ileus often characteristically
remit and recur. This phenomenon has been attributed
to the migration of the stone, with the symptoms likely
to worsen when it becomes impacted in the distal small
bowel
1,3
. Fortunately in our case, further imaging studies
were undertaken, which clarified the diagnosis. At that
point, the patient was able to tolerate the surgery well,
which might not have been the case had management
been delayed.
Gallstone ileus occurs three to five times more fre-
quently in women than in men
1
. The gallstones enter
the intestinal tract through a fistula formed between
the gallbladder and the duodenum, stomach or colon.
A cholecystoduodenal fistula is the most frequent find-
ing, accounting for 83% of cases
3
. Bowel obstruction is
more likely to occur if the stone is larger than 2.5cm, as
A B
Figure 1. (A) Plain abdominal film showing a ventriculoperitoneal shunt and a 32-cm gallstone (arrow) in the right upper
quadrant. The bowel gas is not significantly increased. (B) Abdominal film showing severely distended bowel loops. The gallstone
is now seen in the right lower quadrant (arrow).
Figure 2. Abdominal ultrasound showing a 3-cm hyperechoic
lesion (arrow) with an acoustic shadow in the right lower
quadrant.
International Journal of Gerontology | March 2008 | Vol 2 | No 1 20

C.W. Chang et al
was the case in our patient. The ileum is the most
common site of obstruction (62.5%), followed by the
jejunum (30%), duodenum (2.5%) and colon (2.5%)
6
.
Bouverets syndrome, first described in 1896, is the
unusual situation of gastric obstruction caused by a
gallstone impacted in the duodenum. This syndrome
can be diagnosed and treated endoscopically with stone
extraction or mechanical lithotripsy, but surgery is
necessary in over 90% of cases. The reported mortality
ranges from 1924%
7,8
. Our patients initial symptom
was vomiting, and his stone was first seen in the right
upper quadrant. It is interesting to speculate as to
whether he had transient duodenal obstruction at that
point. His small bowel series and abdominal CT findings
were consistent with a cholecystoduodenal fistula, but
the stone by then had migrated to the distal ileum.
Lassandros group reported the imaging findings
in their 27 patients
5
. On abdominal sonography, they
found pneumobilia in 56% of the patients, dilated bowel
loops in 44%, gallbladder abnormalities in 37%, and
A B
Figure 3. (A) Small bowel barium enema showing an enterobiliary fistula in the right upper quadrant (white arrow) and a
gallstone in the right lower quadrant (black arrow). (B) Small bowel barium enema showing a gallstone apparently impacted
in the distal ileum (black arrow).
A B
Figure 4. (A) Non-enhanced abdominal computed tomography showing a fistula (white arrow) and little barium content in
the biliary tract after small bowel barium enema (black arrow). (B) Non-enhanced abdominal computed tomography show-
ing a hyperdense lesion containing a hypodense ring within it (white arrow) in the right lower quadrant, consistent with
a gallstone.
International Journal of Gerontology | March 2008 | Vol 2 | No 1 21

Gallstones Ileus
extraluminal fluid and ectopic gallstones in 15% each.
In their hands, abdominal CT performed better than
ultrasound for locating ectopic stone (81%). Other CT
findings included dilated bowel loops (93%), pneumo-
bilia (89%), airfluid levels (37%), extraluminal fluid
(22%), and enterobiliary fistulas (15%). Our patients CT
findings were also consistent with those of Lassandro
and colleagues and correlated well with what we saw
on the small bowel series. In cases of small bowel
obstruction, small bowel enema is more accurate in
identifying the presence and location of an obstruc-
tion than CT
9
. We were, in fact, able to see the ectopic
gallstone in the right lower quadrant on plain film,
ultrasound, CT, and small bowel series.
Spontaneous passage of gallstones large enough to
cause impaction has been reported, but most patients
require some type of intervention
10
. If the stone is within
reach of an endoscope, either in the proximal small
bowel or in the colon, it may be treated by lithotripsy
and removal of the fragments
8,1113
. Extracorporeal
shockwave lithotripsy has also been used successfully,
but this method is limited by bowel gas that may shelter
the stone and by the fact that it may be difficult to
identify the gallstone
7,14,15
. Unfortunately, the majority
of patients require surgery, as did ours
16,17
.
In conclusion, this case is a reminder that the diag-
nosis of gallstone ileus must be made in a timely man-
ner. When a large stone is seen on X-ray, particularly in an
older patient whose symptoms and signs are suggestive
of bowel obstruction, gallstone ileus should be consid-
ered in the differential diagnosis. Follow-up X-rays or
supplemental imaging studies should be contemplated.
If typical imaging findings are present, the diagnosis is
straightforward.
Acknowledgments
We thank Dr Mary Jeanne Buttrey for critical reading
and correction of the manuscript.
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