Erika Fellinger, General Surgeon, The Cambridge Hospital, Cambridge, MA; Frederick Rogers, Professor of Surgery and Chief, Division of Trauma, Burns, and Critical Care, University of Vermont, Fletcher Allen Health Care, Burlington, VT
Erika Fellinger, MD
General Surgeon The Cambridge Hospital Cambridge, MA
Frederick Rogers, MD Professor of Surgery and Chief Division of Trauma, Burns, and Critical Care University of Vermont Fletcher Allen Health Care Burlington, VT
Gallstone ileus is an uncommon cause of small bowel obstruction that generally occurs in elderly patients in their seventh decade of life. We report the case of an elderly man whose gallstone ileus was diagnosed by comparing radiographs taken on presentation with earlier films. We also review the literature and discuss the diagnosis and treatment of this condition.
A 76-year-old man came to the emergency department after 5 days of worsening abdominal pain, bloating, nausea, and vomiting. The patient had no history of jaundice or known gallbladder symptomatology. His medical history was significant for constipation, benign prostatic hypertrophy, hypertension, arthritis, ap?pendectomy, lower back surgery, and transurethral resection of the prostate. He was afebrile and appeared mildly dehydrated. The patient had no jaundice. A physical examination revealed bowel sounds and a moderately distended and diffusely tender abdomen without re?bound, guarding, or peritoneal irritation on palpation. His white blood cell count was 13.2 x 103/L, with a mild left shift. An acute abdominal series revealed dilated loops of small bowel consistent with a mechanical partial obstruction. Comparison was made with an abdominal flat plate taken 2 years earlier (Figure 1). A calcified ring shadow seen in the right upper quadrant on the earlier film was now projected over the left iliac bone (Figure 2). There was no pneumobilia.
The clinical diagnosis of gallstone il?eus was made. The patient was admitted over?night for intravenous hydration and ob?servation. A physical examination the following morning revealed his ab?dom?inal condition remained unchanged. A repeated ab?do?m?inal radiograph showed migration of the calcified ring shadow to the left upper quadrant and small bowel obstruction (Figure 3).
Because the patient's physical examination and radiographic findings were consistent with gallstone ileus, he underwent a laparotomy for a planned en?terolithotomy. We found dilated proximal small bowel and distal decompressed bowel around an area in the mid-jejunum in which a hard stone could be palpated. Taking care to protect the wound with towels, we created a longitudinal, approximately 2-cm enterotomy just proximal to the site of obstruction. Pro?ximal to the impacted stone was a large bezoar, which was manually re?moved and squeezed out through the enterotomy. A large, 3.5 x 2.5 x 3.0-cm, mixed-type cholelith was re?moved through the en?terotomy (Figure 4), and the proximal small bowel was de?compressed using the suction device. We closed the enterotomy in a longitudinal fashion because the diameter of the small bowel was sufficiently wide. The ab?domen was then explored, including the liver and large bowel, and the small bowel was run from the Liga?ment of Treitz to the cecum. No more stones were identified. The area around the gallbladder was found to have quite dense fibrotic adhesions between the gallbladder and small bowel. The decision was made to leave the gallbladder and fistula alone. The abdomen was lavaged with several liters of warm saline and the wound was closed in layers. The subcutaneous tissues were irrigated well and the skin closed with skin staples and povidone iodine-soaked Telfa? wicks in between the staples for postoperative control of wound bacteria.
The wicks were removed on postoperative day 1. The patient had one isolated temperature spike to 38.5?C on postoperative day 2. The wounds had no erythema, and a chest radiograph and urinalysis were negative. He recovered well, passed flatus on postoperative day 4, and was discharged to home on postoperative day 6 after tolerating diet advancement.
Gallstone ileus is an uncommon cause of small bowel obstruction, accounting for 1% to 3% of all mechanical bowel obstructions and over 25% of nonstrangulated bowel obstructions in patients older than 65 years.1 It is a complication of cholelithiasis in less than 0.5% of patients. The average age of onset is 72 years, and it occurs in women more commonly than in men, with a reported ratio of 3.5:1.0.1 Patients are often debilitated with multiple medical problems, leading to a reported mortality rate of 15% to 18%.1 Fewer than 20% of gallstones are visible on radiographs, but abdominal flat plate continues to be an important (and less costly) first confirmation of the diagnosis. The classic presentation is Rigler's triad of small bowel obstruction, pneumobilia, and atypical migrating min?eral shadow on plain radiographs.2
The gallstone usually enters the bowel via a cholecystenteric fistula resulting from inflammation and adhesions be?tween the biliary and enteric system following cholecystitis.3 Half of patients, however, do not report a history of biliary symptoms. Cholecystocolonic and cholecystogastric fistulas also have been reported, as have two cases that occurred after endoscopic sphincterotomy.1 The stone travels through the bowel and can lodge in different places along the gastrointestinal (GI) tract. A stone lodged in the duodenal bulb can present as gastric outlet obstruction (Bouveret's syndrome). Most stones settle in the ileum, followed by the jejunum and stomach. Only 1.3% of patients with enteric stones pass them spontaneously via the rectum.1
The treatment of choice is enterolithot-omy and stone extraction, with or without an additional cholecystectomy, and correction of the biliary-enteric fistula in lower-risk patients. A review of 1,001 cases of gallstone ileus by Reisner and Cohen found a higher mortality rate (16.9% versus 11.7%) in patients undergoing a one-stage procedure of stone removal and fistula correction,1 though these results were not statistically significant. Nonoperative mortality was 26.5%. The most common complication was wound infection (32%). Another retrospective comparison showed a complication rate of 61% for patients undergoing concomitant repair of the biliary fistula versus 27% for enterolithotomy alone.2
The reasoning for favoring a one-stage procedure is to prevent future complications resulting from the retained gallbladder. These include recurrence of gallstone ileus, cholecystitis, cholangitis, and a higher incidence of gallbladder carcinoma.1,4 In Reisner and Cohn's review, however, recurrent gallstone ileus was observed in only 6% of patients who un?derwent enterolithotomy alone, and cho?lecystectomy did not prevent this com-?p?lication. Common bile duct stones in pa?tients who had a cholecystectomy and unrecognized stones left in the bowel at the time of surgery were among the causes of recurrence. Multiple stones in the GI tract were found in 3% to 16% of cases.1 Only 15% of patients proceeded to have biliary tract symptoms, and only 10% of those patients underwent surgery to relieve symptoms. Cholangitis was rare, occurring in only two patients in the series. The risk of gallbladder cancer in the retained gallbladder was increased, with an incidence up to 15% (compared with 0.3% of gallbladders removed for other reasons).1 A retrospective comparison of enterolithotomy with cholecystectomy and fistula repair noted that one of 25 patients de?veloped gallbladder carcinoma within 55 months of sur?gery.5 For most patients, the retained gallbladder shrank, atrophied, and became nonfunctional.
Given the relatively low risk of subsequent problems from a retained gallbladder and the debilitated state of most pa?tients presenting with gallstone ileus, the consensus favors enterolithotomy alone, accompanied by aggressive resuscitation, monitoring, correction of electrolyte imbalances, and antibiotics. In a review of 25 cases by Rodriguez-Sanjuan and col?leagues, five of the six patients who died did so as a result of a medical condition unrelated to surgery.5 Age was not related to mortality. The addition of cho?lecystectomy and fistula closure is reasonable in more robust, lower-risk pa?tients who are able to withstand a longer operation.1,2,4,5
Traditionally, an enterolithotomy has required a laparotomy. Several authors have reported using laparoscopic or la?pa?roscopic-assisted techniques to perform the enterolithotomy and the subsequent elective cholecystectomy, common bile duct exploration, choledocholithotomy, and primary bile duct closure.6-8 The one-stage procedure may be undertaken in low-risk patients who can withstand the longer operation and for those patients with acute cholecystitis, a gangrenous gallbladder, or large residual stones.2
Comparing current radiographs with previous films is key in formulating a diagnosis when evaluating patients with abdominal pain. Our patient never underwent a computed tomography scan or further invasive testing. Given the high incidence of older and more debilitated patients presenting with gallstone ileus, a "damage control" mentality may serve to minimize morbidity and mortality. With continued improvement of laparoscopic techniques, the morbidity and mortality from enterolithotomy alone may continue to decrease, lending even more support for this as the procedure of choice in preoperatively diagnosed gallstone ileus. The GI tract should be searched carefully for additional stones at the time of laparotomy.
1. Reisner RM, Cohen JR. Gallstone ileus: a review of 1,001 reported cases. Am Surg. 1994;60(6):441-446.
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3. van Hillo M, van der Vliet JA, Wiggers T, et al. Gallstone obstruction of the intestine: an analysis of ten patients and a review of the literature. Surgery. 1987;101(3):273-276.
4. Clavien PA, Richon J, Burgan S, et al. Gallstone ileus. Br J Surg. 1990;77(7):737-742.
5. Rodriguez-Sanjuan JC, Casado F, Fernandez MJ, et al. Cho?lecystectomy and fistula closure versus enterolithotomy alone in gallstone ileus. Br J Surg. 1997;84(5):634-637.
6. El-Dhuwaib Y, Ammori BJ. Staged and complete laparoscopic management of cholelithiasis in a patient with gallstone ileus and bile duct calculi. Surg Endosc. 2003;17(6):988-989.
7. Lichten JB, Tehrani K, Sekons D. Laparoscopically assisted enterolithotomy for a gallstone ileus in an atypical location. Surg Endosc. 2003;17(9):1496-1497.
8. Agresta F, Bedin N. Gallstone ileus as a complication of acute cholecystitis. Laparoscopic diagnosis and treatment. Surg Endosc. 2000;16(11):1637.