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Gallstone ileus (G.I.) is a mechanical bowel obstruction due to impaction of a large gallstone within the bowel and represents an uncommon complication of cholelithiasis. It accounts for 1–4% of all cases of mechanical bowel obstruction, up to 25% in patients over 65 years of age.
A 75 year old male patient was referred to our hospital in March 2009 with clinical signs of bowel obstruction (abdominal pain and distension, post-prandial vomiting, absolute constipation) during the previous 3 days. A plain abdominal film demonstrated dilated bowel loops, air fluid levels and an image of a stone in the inferior left quadrant. Afterwards, diagnosis of Gallstone ileus was made by means of ultrasonography and colonoscopy. The patient underwent emergent laparotomy and a cholecysto-transverse colon fistula was observed. One-stage procedure consisting of enterolithotomy, cholecystectomy and fistula repair was performed. The post-operative course was complicated by a dehiscence of the colic suture with acute peritonitis. Therefore a colostomy was performed, followed by rapid recovery of general clinical conditions.
Surgical treatment for G.I. by cholecysto-enteric fistula is still controversial. Enterolithotomy alone is best suited in all elderly patients with significant comorbidities. One-stage procedure – enterolithotomy, cholecystectomy and fistula repair – should be reserved for young, fit and low risk patients. In our case, mechanical obstruction was associated with a severe cholecystitis with a large fistula between gallbladder and transverse colon.
A “radical” surgical option could certainly be characterized by a significant morbidity.
Gallstone ileus (GI) is a rare and potentially severe complication of cholelithiasis. It is described as a mechanical obstruction due to the impaction of one or more large gallstones within the bowel. It accounts for 1–4% of all cases of mechanical intestinal obstruction, but up to 25% in patients over 65 years of age, with a female to male ratio of 3.5–6.0:1.1–3
A bilio-enteric fistula, most commonly between gallbladder and duodenum, allows the passage of a large gallstone.6 This will result in its impaction in the bowel, most commonly the terminal ileum or the ileocecal valve, if its diameter is at least 2–2.5 cm2. A bilio-enteric fistula between gallbladder and transverse colon, as occurred in our experience, represents a rare event.
Clinical presentation depends on the site of obstruction, manifesting as acute, intermittent or chronic episodes.7
Diagnosis of GI is difficult, and in about 50% of cases it is made intraoperatively.
The “ideal” surgical treatment is still controversial. However enterolithotomy “alone” remains the most diffuse operation.
Delayed diagnosis, comorbidities and advanced age are the causes of the high related mortality rate (7.5–15%).
A 75 year old male patient was referred to our hospital in March 2009 with clinical signs of intestinal obstruction (abdominal pain and distension, post-prandial vomiting, absence of transit of feces and flatus) during the previous 3 days. He had a past medical history of hypertension and ischemic heart disease. He had undergone double coronary artery bypass surgery at the age of 67 and therefore he was taking warfarin. There was no previous history of gallstone disease.
A mild distension and tenderness on abdominal examination was reported. The white blood count was 18 828/μL. Other laboratory tests were unremarkable.
A plain abdominal film demonstrated dilated bowel loops, air fluid levels and a “vague” image of a stone in the inferior left quadrant (Fig. 1).
Abdominal ultrasounds detected dilated bowel loops, mildly dilated bile ducts with pneumobilia (Fig. 2). Within the gallbladder there was a large gallstone of 25 mm and sludge. Furthermore, ultrasound examination showed continuity between the fundus of the gallbladder and the intestinal wall. Moreover, an ectopic large stone impacted in the left colon lumen was observed, along with other proximally smaller gallstones.
Colonoscopy was performed, showing a large stone impacted in the left colon.
During an emergent laparotomy, distension of bowel loops was found proximal to a palpable stone in the recto-sigmoid junction. The gallbladder presented gallstones and its fundus was adherent to the transverse colon, suggestive of a cholecysto-tranverse colon fistula. Enterolithotomy with handswen colon repair, cholecystectomy and mechanical fistula closure were performed (one-stage surgery). The pathology showed chronic cholecystitis and a fistula walled by granulation tissue. A dehiscence of colonic suture with acute peritonitis was observed on post-operative day 10. Therefore a colostomy was performed with rapid recovery of general clinical condition. In June 2009 the colostomy closure was performed.
GI is a mechanical obstruction caused by one or more large gallstone within the bowel. It accounts for 1–4% of all cases of mechanical intestinal obstruction, mainly in the elderly, with a female to male ratio of 3.5–6.0:1.1–3
Recurrent inflammations due to gallstones determine the onset of bilio-enteric fistula.4,6 The most common fistulas are between the gallbladder and duodenum (60%–86%), ileum and colon, while a fistulous tract with stomach is very rare.
The terminal ileum and the ileocecal valve are the most frequent sites of impaction (50%–75%), followed by proximal ileum and jejunum (20%–40%), stomach, duodenum (10%). The impaction of a gallstone in the colon, as occurred in our experience, represents a rare event.4,7
Clinical presentation of GI, due to the intestinal obstruction, depends on the site of impaction and it may be acute, intermittent or chronic.5 The most common symptoms include nausea, vomiting and epigastric pain.
Diagnosis of GI is difficult, and in about 50% of cases is intraoperative. Diagnostic accuracy of plain abdominal film is about 50%, although only 10% of gallstones are sufficiently calcified to be radiographically visualized.10 Classic findings include: pneumobilia, intestinal obstruction and aberrant gallstone location (Rigler's triad). The presence of at least two of these three signs is considered pathognomonic and is described in 40%–50% of cases.7
Ultrasound, associated to a plain abdominal film, can be used to confirm the pre-operative diagnosis, showing cholelithiasis, and in some cases also fistula may be suspected. 8,9
Regarding bilio-enteric fistula, its location, the number and size of stones, CT scan may improve diagnostic accuracy.7,14,16 Moreover contrast enhanced abdominal CT scan is reported to have the highest specificity and sensitivity in diagnosing G.I.
Surgical treatment is still subject of research. Current operative options are: (1) enterolithotomy alone; (2) enterolithotomy with cholecystectomy performed later (two-stage surgery); (3) enterolithotomy, cholecystectomy and fistula repair (one-stage surgery).
Several factors should be considered in the choice of the most appropriate surgical approach, related to the patient and other diseases (biliary-enteric fistula).
The duration of the bowel obstuction is the most important prognostic factor. In patients with a diagnostic delay, the main goal of the treatment should be the prompt relief of the intestinal obstruction by enterolithotomy alone.
Patient's age and comorbidity may contraindicate a one-stage surgery. Thereby, preoperative stabilization is essential, with a special attention to the fluid and electrolytes balance and the management of comorbid conditions. Furthermore, co-morbidity is associated with an increased risk of postoperative complications (enteric or biliary leakage after the closure of the fistula).
Enterolithotomy alone remains the most common operative method in the majority of cases, because of its low incidence of complications. A spontaneous closure of the fistulous tract is observed in more than 50% of cases.7,10,17
Recently, laparoscopy assisted enterolithotomy and endoscopic removal are becoming the preferred approaches for the treatment of GI.11–13,16
Delayed diagnosis, concomitant comorbidity and advanced age are the causes of an high mortality rate (7.5–15%).1–3
Several studies have shown that the average period of time between the onset of symptomatology and the time of admission goes from 1 to 8 days7,14,15, while time range between admission and operation is 3–4.5 days.5,7
GI is a rare disease and should be suspected in patients with intermittent intestinal occlusion, advanced age, cholelithiasis, and previous episodes of cholecystitis.
Diagnosis is difficult, but occasionally it can be made by a plain abdominal film.
Surgical option represent a debated issue. One-stage procedure should be performed in selected patients of not-advanced age, without important comorbidity. In these selected patients, it is possible to treat the disease in a single emergent surgical time, or sometimes after an appropriate preoperative stabilization of fluid and electrolytes balance.
However, in patients with active symptoms of biliary-reflux and cholecystitis with gallstones, it is necessary to adopt a one-stage strategy.
For this reason, the intra-operative exclusion of the presence of gallstones by palpation of the gallbladder, common bile duct and the entire bowel is critical in choice of the most suitable surgical approach.4,6,7
In the case described by Authors clinical presentation of mechanical ileus associated with severe cholecystitis and a large fistulous tract (more than 2 cm in diameter), between the fundus of the gallbladder and the transverse colon, source of an entero-biliary reflux, encouraged a ‘one stage’ procedure.
Enterolithotomy, cholecystectomy and fistula repair, characterized sometimes by a significant morbidity, can be considered as the best choice, allowing the immediate resolution of the occlusive disease..
The authors have no financial and personal relationships with other people or organisations that could influence our work.
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.
All authors contributed significantly to the present case report and reviewed the entire manuscript.