GALLSTONE ILEUS

Gallstone ileus is an uncommon form of bowel obstruction caused by the impaction of

a large gallstone in the intestinal lumen. The term “ileus” is actually a misnomer because
the condition represents a true mechanical obstruction of the intestine.

Epidemiology
Gallstone ileus is an unusual cause of small bowel obstruction and accounts for only
about 1%-4% of all small bowel obstruction cases. The median age of presentation is 70
y/o, and is more prevalent in women than men. Gallstone ileus is a complication of
cholelithiasis.

Pathophysiology
In the setting of acute or chronic cholelithiasis, the gallbladder is inflamed and distended
causing the gallbladder wall to be adherent to the duodenum. The ongoing inflammation
and distention then result in pressure necrosis, erosion, and formation of a fistula, called
“cholecystoenteric fistula”. If a gallstone of >2.5 cm is passed into the duodenum, this
might cause an impaction into the small intestine (in the absence of an intestinal stricture,
a gallstone of at least 2 cm is required to cause intestinal obstruction). Impaction occurs
most commonly in the terminal ileum, just before entering the cecum (ileocecal valve).
Clinical Presentation
Gallstone ileus present with symptoms typical of mechanical intestinal obstruction such
as cramping abdominal pain, vomiting, and abdominal distention. The obstruction has
been described as “tumbling,” because the symptoms wax and wane during the passage
of the stone. Only a minority have symptoms of acute cholecystitis, but one–half are
known to have a history of gallstones. The most common site of obstruction is the ileum,
accounting dor about 60% of cases; this is followed by the jejunum (15%), stomach
(15%), and colon (5%). The diagnosis of gallstone ileus is delayed in up to half of the
patients because of nonspecific and inconsistent symptoms. Only 50% to 70% of patients
have clinical features of SBO. Liver biochemical tests are elevated in about 40% of
patients but overt jaundice is rare.

Imaging Techniques
The classic radiologic features of gallstone ileus include pneumobilia, intestinal
obstruction, aberrant gallstone location or a change in the location of a previously
observed stone. This is also known as the Rigler triad. Only about 10% of gallstones are
sufficiently calcified to be identified on abdominal plain films.

Plain abdominal films reveal an intestinal gas pattern compatible with intestinal
obstruction in most patients (air-fluid levels). Pneumobilia is present in about one half of
all patients, and the aberrant gallstone is visible in a minority. Upper or lower
gastrointestinal barium studies may occasionally identify the site of obstruction or the
fistula, but these tests are unnecessary in most cases. Ultrasonography is useful for
confirming the presence of cholelithiasis and may allow visualization of the fistula. The
Rigler triad is better seen on CT scan than on plain radiograph. Additionally, the site of
fistulization is seen (Rigler tetrad). It is important to look for free fluid, free gas, portal
venous gas, or mural gas, as signs of more advanced disease and poorer prognosis.

Plain abdominal film showing (1) pneumobilia, (2) distended CT scan showing the Rigler tetrad: intrahepatic biliary gas, dilated small
bowel loops, and (3) aberrant gallstone location. bowel, cholecysto-enteric fistula, and intraluminal stone.
Small Bowel Obstruction

Since gallstone ileus is a type of small bowel obstruction, it is important for us to know its
pathophysiology, clinical presentation, diagnosis, and initial treatment.

Pathophysiology
With the onset of small bowel obstruction, gas and fluid accumulate proximal to the site
of obstruction which manifests as dilatation and air-fluid levels. Intestinal activity then
increases in an effort to overcome the obstruction leading to hyperactive bowel sounds,
colicky pain, and diarrhea that some experience even in the presence of complete bowel
obstruction. Gallstone ileus is mostly a complete obstruction of the ileum. With ongoing
gas and fluid accumulation, the bowel distends and intramural and intraluminal pressures
rises. Gas mostly originates from swallowed air, while some is produced in intestine and
fluid consists of swallowed liquids and gastrointestinal secretions. Obstruction also
stimulates intestinal epithelial water secretion. The intestinal motility is eventually reduced
with fewer contractions. With obstruction, the luminal flora of the small bowel, which is
usually sterile, changes due to bacterial translocation to the regional lymph nodes and
this results to a feculent vomit. If the intramural pressure is high enough, intestinal
microvascular perfusion is impaired leading to intestinal ischemia and necrosis, resulting
to a strangulated bowel obstruction.

Clinical Presentation
Patients with small bowel obstruction typically present with colicky abdominal pain,
nausea, vomiting. In history taking it is important to characterize the vomit as whether
feculent or not, as this gives the physician an idea about the duration. One must also ask
about the passage of flatus or stool, giving a clue whether the obstruction is partial or
complete. Upon physical examination one might note of abdominal distention, which is
pronounced if the obstruction is in distal ileum, and may be absent if in proximal small
bowel. On auscultation, initially there are hyperactive bowel sounds. Hypoactive bowel
sounds are an ominous sign. Laboratory investigations may show intravascular volume
depletion, hemoconcentration, electrolyte abnormalities, and mild leukocytosis. One must
watch out for abdominal pain disproportionate to abdominal findings, tachycardia,
localized abdominal tenderness, fever, marked leukocytosis, and acidosis as these are
features of strangulated obstruction and warrant urgent intervention.

Imaging Techniques
Diagnosis of small bowel obstruction is usually confirmed with radiographic examination.
The abdominal series consists of (a) a radiograph of the abdomen in an upright position,
(b) in a supine position, and (c) radiograph of the chest in an upright position. The finding
most specific for small bowel obstruction is the triad of dilated small bowel loops (>3 cm
in diameter), air-fluid levels seen on upright films, and a paucity of air in the colon. CT
scanning is 80% to 90% sensitive and 70% to 90% specific in the detection of small bowel
obstruction. The findings of SBO include a discrete transition zone with dilation of bowel
proximally, decompression of bowel distally, intraluminal contrast that does not pass
beyond the transition zone, and a colon containing little gas or fluid.
Initial Management of Small Bowel Obstruction
Small bowel obstruction is usually associated with a marked depletion of intravascular
volume due to decreased oral intake, vomiting, and sequestration of fluid in bowel lumen
and wall. Therefore, fluid resuscitation is integral to treatment. Isotonic fluid should be
given intravenously, and an indwelling bladder catheter may be placed to monitor urine
output. Broad-spectrum antibiotics are given by some because of concerns that bacterial
translocation may occur in the setting of small bowel obstruction. The stomach should be
continuously evacuated of air and fluid using a nasogastric (NG) tube. Effective gastric
decompression decreases nausea, distention, and the risk of vomiting and aspiration.

Definitive Treatment of Gallstone Ileus

Gallstone ileus is a surgical disorder and treatment is focused on removing the
obstructing stone, usually by operative enterolithotomy. This is done by removing the
stone via a small enterotomy wherein a longitudinal incision on the antimesenteric border
of the ileum is made a few centimeters proximal to the stone. Bowel resection is
necessary only when perforation or intestinal ischemia has already occurred. A search
should be made for additional stones by palpation of the remaining small intestine to
exclude a second stone that could cause a recurrent obstruction. Closure of the
cholecystoenteric fistula is not necessary at the initial operation because many fistulas
close spontaneously. Elective cholecystectomy is also generally performed after the
patient has recovered from the initial operation. This is because the intense inflammatory
process in the RUQ may complicate the cholecystectomy and duodenal repair. In
addition, because most of these patients are older, their overall physiologic status may
not permit fistula repair in the emergent setting.

In summary, the definitive treatment of gallstone ileus may be a one-stage procedure or

a two-stage procedure. The one-stage procedure, which is recommended only for the
younger, healthy patients consist of enterolithotomy, cholecystectomy, and repair of
cholecystoenteric fistula which is done in one setting. The two-stage procedure consist
of enterolithotomy and an interval cholecystectomy.
Mirizzi Syndrome

Mirizzi syndrome is a rare condition caused by the

obstruction of the common bile duct or common
hepatic duct by external compression from
multiple impacted gallstones or a single large
impacted gallstone in Hartman's pouch.

Presenting symptoms are similar to symptoms of

cholecystitis with the addition of jaundice. As
such, this condition may be confused with other
obstructive conditions such as choledocholithiasis
or ascending cholangitis due to the presence of
jaundice. Patients with advanced Mirizzi
syndrome or more severe acute cholecystitis may
present with more pronounced symptoms and
findings.

Mirizzi syndrome is usually classified

according to the Csendes classification
and management depends on the type.
The treatment for Mirizzi syndrome is
cholecystectomy. If a fistula is present,
such as in Type V, then an open
cholecystectomy with
bilienteric anastomosis, possibly with a
Roux-en-Y anastomosis. In general
surgery, a Roux-en-Y anastomosis, or
Roux-en-Y, is an end-to-side surgical
anastomosis of bowel used to
reconstruct the gastrointestinal tract.
Bouveret’s Syndrome

Bouveret’s syndrome refers to

impaction of a gallstone in the distal
duodenum or at the pylorus with
resulting symptoms of gastric outlet
obstruction caused by a large stone
passing through a cholecystoduodenal
fistula. Bouveret syndrome is the most
infrequent variant of gallstone ileus,
with a little over 300 cases in literature
since its first description in 1654
through 2008.

The presentation is typically non-specific: waxing and waning symptoms of nausea and
vomiting, abdominal distension and pain, epigastric and right hypochondrium pain, signs
of dehydration and weight loss, and intensity of the pain disproportional to underlying
condition. Less frequently, Bouveret syndrome may present with hematemesis secondary
to duodenal and celiac artery erosions or with the expulsion of stones in the vomitus.
Usually, the symptoms begin 5 to 7 days before patients seek medical consultation.

Treatment options may be a one-stage procedure (enterolithotomy to relieve bowel

obstruction, cholecystectomy, and repair of chole-enteric fistula), a two-stage procedure
(enterolithotomy and interval cholecystectomy), or an enterolithotomy alone.

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