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| CASE REPORT |
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| Year : 2020 | Volume
: 34
| Issue : 2 | Page : 111-114 |
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Gallstone ileus: Rare life-threatening disease
Pranjal Kumar Dhekiyal Phukan, Anup Kumar Roy
Department of Surgery, Down Town Hospital, Guwahati, Assam, India
| Date of Submission | 15-Nov-2018 |
| Date of Decision | 08-Sep-2020 |
| Date of Acceptance | 18-Nov-2020 |
| Date of Web Publication | 25-Jan-2021 |
Correspondence Address:
Anup Kumar Roy
Department of Surgery, Down Town Hospital, Dispur, Guwahati - 781 006, Assam
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jms.jms_86_18
Gallstone ileus is an uncommon complication of calculus cholecystitis and often presents as a life-threatening emergency. It is more common in the elderly and especially among females. It is a rare cause of intestinal obstruction and accounting for 1%–4% of cases. Patients present with symptoms of intestinal obstruction such as abdominal pain, vomiting, and abdominal distension. Diagnosis can be confirmed by computerized tomography (CT) of the abdomen. Enterolithotomy is the most accepted treatment of choice. We report a case of 55-year-old female who presented with epigastric pain for 8 days duration with multiple episodes of vomiting and progressive abdominal distension. Classical Rigler's triad was observed. CT of the abdomen was suggestive of a gallstone obstructing the small bowel. Enterolithotomy with primary bowel repair was done. A large gallstone of size 5 cm × 3 cm was extracted from the terminal ileum. Postoperative period was uneventful. This case is being reported to highlight the rare incidence of gallstone ileus and its life-threatening surgical emergency, particularly large gallstone causing obstruction, and impending bowel gangrene.
Keywords: Enterolithotomy, gallstone ileus, impending gangrene, small bowel obstruction
How to cite this article:
Dhekiyal Phukan PK, Roy AK. Gallstone ileus: Rare life-threatening disease. J Med Soc 2020;34:111-4 |
| Introduction | |  |
Gallstone ileus is a misnomer and not a true ileus. It is characterized by mechanical obstruction of the small intestine due to impaction of one or more gallstones.[1],[2] Bartholin was the first to describe it in 1654.[3] Later Courvoisier described 131 cases of mechanical intestinal obstruction caused by gallstones in the lumen of small bowel with a surgical mortality around 50% in 1890.[3] It is an uncommon and potentially life-threatening complication of calculus cholecystitis. It develops in 0.3–03 percent of all patients with cholelithiasis.[4] It mainly affects the elderly population, especially females, and is a rare cause of mechanical small bowel obstruction. The incidence is 1%–4% of all cases of small bowel obstruction and this increase to 25% for nonstrangulated obstruction of the small bowel in patients aged over 65 years.[2],[5] The mortality associated with gallstone ileus is 12%–27% if not diagnosed early and in the presence of comorbid conditions.[5] The disease most commonly occurs due to the formation of cholecystoenteric fistula which is sequelae of acute or chronic calculous cholecystitis. Although the curative management is surgical there are no accepted standard surgical procedures.[5],[6] We report a case of 55-year-old female who came with signs of life-threatening intestinal obstruction with sepsis and found to have a large gallstone in the terminal ileum. Simple enterolithotomy with primary bowel repair was done under general anesthesia.
| Case Report | | |
A 55-year-old previously healthy female presented with complaints of abdominal pain for 8 days' duration which was epigastric in location, sudden in onset, gradually progressive, severe in nature, nonradiating, and associated with multiple episodes of projectile vomiting. The vomitus contained food particles initially and later turned bilious. This was followed by progressive abdominal distension and obstipation for 3–4 days. There was no history of jaundice, fever, or loss of weight. Initially, the patient was treated at a local hospital as a case of chronic calculus cholecystitis and later referred to our hospital when her condition deteriorated.
On examination, the patient was conscious, co-operative and oriented to time, place, and person. She was pale, dehydrated, and had tachycardia (HR116 bpm). Blood pressure was 90/60 mm Hg. The abdomen was grossly distended, tender, and had diffuse guarding with sluggish bowel sounds. Rectal examination showed an empty rectum. She was admitted and resuscitated. Routine blood examinations revealed total leukocyte count of 38,400, C-reactive protein >200 mg/L and procalcitonin levels >100 ng/dl. Her liver function test (LFT) was deranged with mild elevations of transaminases and alkaline phosphatase. Contrast-enhanced computed tomography of the abdomen showed pneumobilia, intestinal obstruction, and ectopic gallstone suggestive of classical Rigler's triad [Figure 1]. Broad-spectrum antibiotics were initiated. After resuscitation, the patient was taken up for exploratory laparotomy which revealed grossly dilated small bowel loops and dense adhesions with inflammatory changes in the gallbladder (GB) fossa [Figure 2]. A large stone was palpated at 12 cm proximal to the ileocaecal junction [Figure 3]. Enterolithotomy and primary repair of bowel were done in two layers [Figure 4]. The patient's condition improved after surgery. The patient had an uneventful hospital stay and she was discharged on postoperative day 5. On 1 month postoperative follow-up, the patient was doing well and had no postoperative complications. | Figure 1: Computerized tomography showing air in the gallbladder (white arrow)
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 | Figure 2: Computerized tomography showing gallstone in the terminal ileum (white arrow)
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| Discussion | | |
Gallstone ileus is a very rare condition and may present as life-threatening acute intestinal obstruction. It mostly affects elderly females and the female–-to-male ratio is 3.5–1[6] which was also observed in our case. It is an uncommon and late complication of calculous cholecystitis. The basic etiology is the impaction of one or more gallstones in the gastrointestinal tract causing mechanical obstruction. Gallstones reach the intestine through either a cystometric fistula in 80%–85% of cases or through the common bile duct and through a dilated papilla of Vater in 15%–20% of cases.[7] In our case, the patient gave a history of repeated abdominal pain over the years which resulted in chronic calculus cholecystitis with subsequent development of fistula and passage of calculus to the bowel. The most common site of obstruction is the ileum (60.5% of cases) as the lumen is narrow here with comparatively less peristaltic movements[8] which was found to be the exact spot in our case too. Other sites are jejunum (16.1%), stomach (14.2%), colon (4.1%), and duodenum (3.5%).[8] It can also be passed spontaneously (1.3%)[8] or this process might be part of the natural history of Mirizzi syndrome.[9] Size of the gallstone is usually >2.5 cm.[10],[11],[12] In our patient, however, the size was found to be 5 cm large [Figure 5] and [Figure 6]. | Figure 5: Large gallstone felt at the terminal ileum and enterostomy done
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 | Figure 6: Primary bowel repair was done and this large stone was extracted
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Clinically patients present with complaints of abdominal pain, vomiting, abdominal distension, and absolute constipation which suggests the diagnosis of acute intestinal obstruction. Preoperative diagnosis is around 40%–50% and there is usually a delay in diagnosis. Mortality and morbidity increases in view of comorbidities in the elderly and many patients land up in hospital with life-threatening bowel obstruction with or without sepsis and shock as was the case in our patient as she landed up in the emergency with severe intestinal obstruction, sepsis, and septic shock with clinical suspicion of impending bowel rupture.
Routine laboratory investigations may show leukocytosis, deranged LFT, and electrolytes which carry less significance. In addition to the above evidence of sepsis with septic shock was also observed in our patient. Classical Rigler's triad, i.e., pneumobilia, intestinal obstruction, and the presence of ectopic gall stone was observed in computerized tomography (CT) of the abdomen but can be seen in plain X-ray of the abdomen also. Although it has only 40%–50% sensitivity,[13] CT abdomen with its sensitivity and specificity, and diagnostic accuracy of 93%, 100%, and 99%, respectively, is far superior than ultrasound or X-ray.[14] CT with its high resolution can show the multiple air-fluid levels, exact location of the stone, and other abnormalities if any.
The management of gallstone ileus is essentially surgical which focuses on relieving the obstruction and preserving life. Surgical options are (a) Enterolithotomy and extraction of stone alone, (b) enterolithotomy, cholecystectomy, and fistula closure, (c) bowel resection and fistula closure.[15],[16] we also opted for the first option as there were dense adhesions in the GB fossa resulting in nonvisualization of the fistula. Laparoscopic or endoscopic retrieval of stone and extracorporeal shock wave lithotripsy are other options available, but we opted for open approach as there was a high suspicion of impending rupture with the presence of documented sepsis.
Two-stage procedure, i.e., enterolithotomy and stone exaction and cholecystectomy with fistula closure at a later date generally after 4–6 weeks is the most preferred approach as the carry lower risks.
| Conclusion | | |
Gallstone ileus is a rare cause of intestinal obstruction and affects mainly the elderly females. It can become life-threatening in presence of large stone causing impending bowel gangrene and in the presence of sepsis or shock. Diagnosis is usually delayed and can be made by plain X-ray of the abdomen or CT abdomen. Two-stage procedures such as enterolithotomy with stone extraction and cholecystectomy with fistula closure are the most accepted choice of surgery as it has lower risks and complications.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
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