Gallstone Ileus


Article Author:
Anisha Turner
Bashar Sharma


Article Editor:
Sandeep Mukherjee


Editors In Chief:
Kranthi Sitammagari
Mayank Singhal


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Kyle Blair
Trevor Nezwek
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Daniyal Ameen
Altif Muneeb
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes
Komal Shaheen
Sandeep Sekhon


Updated:
6/27/2019 11:23:46 AM

Introduction

Gallstone ileus is a rare complication of cholelithiasis and is one of the rarest forms of all mechanical bowel obstructions. It is, however, a more common cause of non-strangulating mechanical small bowel obstruction, accounting for 1% to 4% in all patients and up to 25% in the elderly. The diagnosis is often delayed since symptoms may be intermittent and investigations may fail to identify the cause of the obstruction. As a result, gallstone ileus continues to be associated with relatively high rates of morbidity and mortality. [1][2][3]

Etiology

It was first described in 1654 by Dr. Erasmus Bartholin and is thought to be caused by impaction of a gallstone in the gastrointestinal (GI) tract after passing through a biliary-enteric fistula. Gallstone ileus is more common in women (the ratio being 3.5 females to 1 male) and older patients, particularly those older than 60 years. Other factors that contribute to gallstone ileus are a long history of cholelithiasis, repeated episodes of acute cholecystitis, and stones greater than 2 cm. According to literature, approximately 40% to 50% of patients eventually diagnosed with gallstone ileus have a history of recent biliary colic bouts, jaundice, or acute cholecystitis.[4][5]

Epidemiology

Gallstone ileus occurs in 0.3% to 0.5% of all patients with gallstones, and one of the rarest causes of gallstone ileus, occurring in about less than 0.1% of all mechanical obstruction cases and 1% to 4% of non-strangulating mechanical small bowel obstructions. Despite 350 years of medical advances, mortality remains high, ranging from 12% to 27%, partially because of non-specific symptoms, unremarkable biochemical investigations, high misdiagnosis rate, and delayed discovery.

Pathophysiology

The etiology of gallstone ileus results from adhesions forming between an inflamed gallbladder and an adjacent GI tract followed by gallstones causing pressure necrosis or inflammation between the two tissues.  The inflammation or necrosis results in erosion and formation of a cholecyst-enteric fistula. Gallstones can move from the gallbladder to the GI tract through this direct access. Fistulas can form within any part of the GI tract, with approximately 60% occurring in the duodenum due to the proximity. Less commonly, a gallstone may enter the duodenum through the common bile duct, a dilated papilla of Vater, or after an endoscopic sphincterotomy. Spillage of gallstones during laparoscopic cholecystectomy may also result in an intraabdominal abscess that can ulcerate the intestinal wall and lead to an entryway into the bowel lumen. The site of fistula formation, size of gallstone, and size of bowel lumen will determine the location of impaction.  Gallstones most commonly impact at the terminal ileum and ileocecal valve due to their narrow lumen and potentially less active peristalsis.  The majority of gallstones smaller than 2 cm may pass spontaneously while those larger are more likely to become impacted. The presence of diverticula, strictures or neoplasms can also serve as impaction sites.[6][7]

History and Physical

Unfortunately, the diagnosis is often delayed since symptoms may be non-specific, intermittent or investigations fail to identify the cause of the obstruction due to the “tumbling phenomenon” as the stone tumbles through the variable portions of the GI tract. Patients typically present 4 to 8 days after symptoms start. The signs and symptoms are usually non-specific, including crampy, intermittent abdominal pain, variable abdominal distention, nausea, vomiting, and constipation intermittently as the stone travels through the GI tract. The degree of obstruction will vary based on the location of the gallstone, and occasionally the gallstone passes through the rectum without notice. The physical examination may be non-specific, but a provider may appreciate abdominal distension, abdominal tenderness, high-pitched bowel sounds, and obstructive jaundice.  Importantly, the intensity of the pain often does not correlate with the underlying anatomic alteration.

Evaluation

The diagnosis is usually made three to eight days after symptoms, and a correct preoperative diagnosis is reported in 30% to 70% of cases. As a result, a high index of suspicion is necessary. Laboratory studies are usually non-specific, as only one-third of patients present with jaundice and/or alteration of hepatic enzymes. Ultrasound can be used to demonstrate fistulas, pneumobilia, impacted gallstones and residual cholelithiasis or choledocholithiasis, but difficulties of locating stones and distortion by bowel gas make ultrasound suboptimal. Plain abdominal radiographs can also be used for diagnosis, with Rigler’s triad being present in some cases with partial or complete intestinal obstruction, pneumobilia or contrast in the biliary tree, and an ectopic gallstone. The gallstone can change position on serial films. The sensitivity ranges from 40% to 70%. CT scanning is a better entity and has a sensitivity of 93%. Balthazar et al. described a fifth sign: two air-fluid levels in the right upper quadrant on abdominal radiograph corresponding to the duodenum and the lateral to the gallbladder, yet this sign is only present in approximately 24% of patients at the time of admission. Therefore, if you have a clinical suspicion but negative x-ray findings, a CT scan should be performed. Findings consistent with gallstone ileus include gallbladder wall thickening, pneumobilia, intestinal obstruction, and obstructing gallstones. Pneumobilia, a non-specific findings, is found in approximately 30% to 60% of patients. HIDA scan, MRCP, and EGD may be performed if there is still a question after CT scanning. However, gallstone ileus is more typically diagnosed intra-operatively when a patient is undergoing laparotomy for small bowel obstruction of unknown origin. [5][8][9]

Treatment / Management

Although the treatment and management of gallstone ileus are still under controversy, the main therapeutic goal is the extraction of the offending stone after resuscitation. Gallstone ileus involves three key elements: cholelithiasis, biliary-enteric fistula, and intestinal obstruction. Cholelithiasis and fistula are typically addressed by stone removal and fistula closure. Stone removal typically addresses intestinal obstruction. The current surgical options are 1) simple entero-lithotomy; 2) entero-lithotomy, cholecystectomy and fistula closure (one-stage procedure); and 3) entero-lithotomy with cholecystectomy performed later (two-stage procedure). Most conclude that entero-lithotomy alone is the best option for most patients. Some have advocated that one-stage procedure (cholecystectomy and fistula repair) should be considered in low-risk patients in good general condition and adequately stabilized preoperatively. A two-stage surgery is usually an option for those with persistent symptoms despite entero-lithotomy surgery. Whether interval biliary surgery should be performed at the same time as the obstruction relief (one-stage procedure), performed later, or not at all remains unanswered. [3][10][11]

Differential Diagnosis

  • Acute pancreatitis
  • Bile duct stones
  • Cholecystitis
  • Bile duct malignancy
  • Peptic ulcer disease

Complications

Complications may include bowel obstruction, infection, and pancreatitis.

Pearls and Other Issues

An open procedure is the "gold standard" to treat this condition. It is difficult to examine the distended bowel and find the exact location of the gallstone during laparoscopy. Plus, laparoscopy does take a longer time to perform and needs more experienced surgeons. Some reports do indicate that that the laparoscopic enterolithotomy and classic surgery can produce good results and may help with diagnosis and also be therapeutic.

Enhancing Healthcare Team Outcomes

Gallstone ileus is usually managed by several different healthcare specialists which includes a radiologist, a gastroenterologist, and a general surgeon. Since most of these patients are frail seniors, a critical care specialist should be involved in their care before and after surgery.

The nurse plays a vital role in the education patients with symptoms of biliary colic and acute pancreatitis. The patient should be educated about the symptoms of gallstone ileus and when to seek medical help. Further, when the patient is admitted with bowel obstruction, the nurse should closely monitor the abdominal girth, urine output, and Nasogastric residuals. These patients are elderly and are also at risk for DVT and aspiration pneumonia- hence appropriate precautions should be taken. Finally, since obesity is a risk factor for gallstones, patients should be urged to lose weight, eat a healthy diet and exercise regularly. [12][13] (Level V)

Outcomes

Only anecdotal reports and small case series exist on the management of gallstone ileus. If the diagnosis is delayed, it carries a mortality rate of 15-30%. Further, these patients have a prolonged stay in the hospital and develop a wide range of complications such as a prolonged ileus, recurrent bowel obstruction, aspiration pneumonia, and fistulas. [9][14](Level III)


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Gallstone Ileus - Questions

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A 65-year-old female is suspected of having gallstone ileus. Which of the following is false about the condition?



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A 65-year-old female is found to have gallstone ileus. Which of the following is false about this disorder?



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Which is false about gallstone ileus?



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What does gallstone ileus cause?



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Which of the following is the most likely diagnosis for a 63-year-old with a history of gallstones who presents with a bowel obstruction?



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A 55-year-old female presented with a history of hypercholesterolemia and cholelithiasis with recurrent biliary colic presented with a 1-week duration of intermittent abdominal pain, nausea, and vomiting. She described the pain as intermittent cramps. On exam, she had mild right upper quadrant tenderness without rigidity and increased bowel sounds. Vitals were stable. Labs were significant for WBC 12000/microliter. Abdominal ultrasound was unclear due to bowel gas. CT abdomen showed multiple small bowel air-fluid levels with gallbladder wall thickening, gallstones, and pneumobilia. What is the best next step in the management?



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A 60-year-old female presented with intermittent abdominal pain of 1-week duration, associated with nausea and vomiting. On exam, she had mild abdominal tenderness without rigidity. She also had hyper-resonant bowel sounds. Vitals were stable. Labs were significant for WBC 11000/microliter. CT abdomen showed cholelithiasis, pneumobilia, dilated small intestines with multiple air-fluid levels and a stone at the terminal ileum. What is the likely site of entry of the stone into the bowel?



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A 70-year-old male with a history of hypercholesterolemia and hypertension presented with a 10-day history of intermittent abdominal pain, nausea, and vomiting. He described the pain as intermittent cramps that are associated with nausea and episodes of vomiting. On exam, he had diffuse abdominal tenderness without rigidity and hypertympanic bowel sounds. Vitals were stable. Labs were significant for two-fold elevations in alanine aminotransferase (ALT) and aspartate aminotransferase (AST). Abdominal x-ray showed multiple small bowel air-fluid levels. Abdominal ultrasound showed cholestasis and pneumobilia. What is the likely site of obstruction?



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Gallstone Ileus - References

References

Creedon L,Boyd-Carson H,Lund J, A curious case of cololithiasis. Annals of the Royal College of Surgeons of England. 2018 Aug 16     [PubMed]
Teelucksingh S,Boppana LKT,Goli S,Naraynsingh V, Gallstone ileus 1 year after cholecystectomy. Journal of surgical case reports. 2018 Jul     [PubMed]
Ferretti C,Fuks D,Wind P,Zarzavadjian Le Bian A, Laparoscopic management of sigmoid colon gallstone ileus. Techniques in coloproctology. 2018 Jul 6     [PubMed]
Inukai K,Uehara S,Miyai H,Takashima N,Yamamoto M,Kobayashi K,Tanaka M,Hayakawa T, Sigmoid gallstone ileus: A case report and literature review in Japan. International journal of surgery case reports. 2018     [PubMed]
Hussain J,Alrashed AM,Alkhadher T,Wood S,Behbehani AD,Termos S, Gall stone ileus: Unfamiliar cause of bowel obstruction. Case report and literature review. International journal of surgery case reports. 2018     [PubMed]
Ong J,Swift C,Ong S, Bouveret's Syndrome: Sense and Sensitivity. Journal of community hospital internal medicine perspectives. 2018     [PubMed]
Roade Tato L,Ventura Cots M,Riveiro-Barciela M, Gallstone ileus secondary to a cholecystocolonic fistula. Gastroenterologia y hepatologia. 2018 Jun 7     [PubMed]
Salazar-Jiménez MI,Alvarado-Durán J,Fermín-Contreras MR,Rivero-Yáñez F,Lupian-Angulo AI,Herrera-González A, [Gallstone ileus, surgical management review]. Cirugia y cirujanos. 2018     [PubMed]
Farkas N,Kaur V,Shanmuganandan A,Black J,Redon C,Frampton AE,West N, A systematic review of gallstone sigmoid ileus management. Annals of medicine and surgery (2012). 2018 Mar     [PubMed]
Inukai K,Tsuji E,Takashima N,Yamamoto M, Laparoscopic two-stage procedure for gallstone ileus. Journal of minimal access surgery. 2018 Jun 27     [PubMed]
Ploneda-Valencia CF,Gallo-Morales M,Rinchon C,Navarro-Muñiz E,Bautista-López CA,de la Cerda-Trujillo LF,Rea-Azpeitia LA,López-Lizarraga CR, Gallstone ileus: An overview of the literature. Revista de gastroenterologia de Mexico. 2017 Jul - Sep     [PubMed]
Schirmer BD,Winters KL,Edlich RF, Cholelithiasis and cholecystitis. Journal of long-term effects of medical implants. 2005     [PubMed]
Portincasa P,Di Ciaula A,de Bari O,Garruti G,Palmieri VO,Wang DQ, Management of gallstones and its related complications. Expert review of gastroenterology     [PubMed]
Scuderi V,Adamo V,Naddeo M,Di Natale W,Boglione L,Cavalli S, Gallstone ileus: monocentric experience looking for the adequate approach. Updates in surgery. 2017 Oct 10     [PubMed]

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