Gallstone ileus: diagnostic pitfalls and therapeutic successes

Gallstone Ileus as an Occult Cause of Small Bowel Obstruction and Subsequent Large Bowel Obstruction: A Report of a Rare Case

Gallstone ileus, a rare cause of mechanical bowel obstruction, occurs due to the formation of a cholecystenteric fistula allowing gallstones to migrate into the gastrointestinal tract. The condition occurs mostly in elderly patients, particularly women, and carries a significant mortality risk due to delayed diagnosis. This case report discusses a 77-year-old female patient with a history of chronic medical conditions, who self-presented with periumbilical pain, nausea, and reduced bowel movements. Initial imaging revealed pneumobilia and small bowel obstruction, leading to a diagnosis of partial obstruction attributed to adhesions. Despite surgical intervention and temporary symptom relief, the patient's condition deteriorated due to a subsequent colonic obstruction. The case was complicated by delayed recognition of gallstone ileus, as imaging initially misinterpreted the obstructive mass as a "stool ball" rather than a gallstone. Following diagnostic laparoscopy and subsequent exploratory surgeries, the patient was found to have a gallstone impacted in the rectum, leading to colonic ischemia and perforation. This resulted in progressive renal failure, respiratory failure, and ultimately, the patient's death in hospice care. This case underscores the diagnostic challenges of gallstone ileus and highlights two key delays: misattribution of obstructive symptoms to adhesions and failure to recognize colonic obstruction due to gallstone ileus. Early use of contrast-enhanced imaging and a high index of suspicion are crucial for timely diagnosis. This case emphasizes the importance of thorough inspection of the small bowel and ileocecal region during laparoscopy and the need for careful evaluation of imaging findings to improve patient outcomes in gallstone ileus cases.

Traveling gallstones: review of MR imaging and surgical pathology features of gallstone disease and its complications in the gallbladder and beyond

Gallstone-related disease comprises a spectrum of conditions resulting from biliary stone formation, leading to obstruction and inflammatory complications. These can significantly impact patient quality of life and carry high morbidity if not accurately detected. Appropriate imaging is essential for evaluating the extent of gallstone disease and assuring appropriate clinical management. Magnetic Resonance Imaging (MRI) techniques (including Magnetic Resonance Cholangiopancreatography (MRCP) are increasingly used for diagnosis of gallstone disease and its complications and provide high contrast resolution and facilitate tissue-level assessment of gallstone disease processes. In this review we seek to delve deep into the spectrum of MR imaging in diagnose of gallstone-related disease within the gallbladder and complications related to migration of the gallstones to the gall bladder neck or cystic duct, common hepatic duct or bile duct (choledocholithiasis) and beyond, including gallstone pancreatitis, gallstone ileus, Bouveret syndrome, and dropped gallstones, by offering key examples from our practice. Furthermore, we will specifically highlight the crucial role of MRI and MRCP for enhancing diagnostic accuracy and improving patient outcomes in gallstone-related disease and showcase relevant surgical pathology specimens of various gallstone related complications.

Gallstone ileus: Unusual complication of cholelithiasis: A case report

Introduction and importance

Gallstone ileus is a rare cause of intestinal obstruction with a high morbidity and mortality rate, which is often linked to delayed or misdiagnosed intestinal obstruction. Gallstone ileus requires a high index of suspicion to diagnose.

Case presentation

This report describes a 55-year-old male who presented the case of gallstone ileus with four years history of gallstone disease, emergency explorative laparotomy was done, enterotomy and stone extraction from the small bowel, the post-operative patient was uneventful and was discharged after full enteral tolerance.

Clinical discussion

CT scanning has become increasingly important as a diagnostic tool, with a sensitivity of 93% and its use has increased in recent years, In the case of patients with gallstone ileus, simple enterolithotomy is both safe and effective.

Conclusions

Gallstone Ileus is an uncommon complication of gallstone disease, most commonly seen in females in advanced age, our case report presents young adult male and high index suspicion in diagnosis and urgent intervention is mandatory for better outcome of the patients.

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Generally this condition is seen in female with advanced age, but this case, reports atypical presentation of the disease according patient age and gender.

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Will raise awareness among patients who have a delayed presentation of the disease and acquire challenges associated to gallstones, such as gallstone illeus.

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To illustrate all necessary requirement of diagnosis and management of disease. Including classic radiological features and relevant intra-operative images.

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Summarize the surgical techniques performed to management gallstone ileus.

Rolling in the Deep: Imaging Findings and Diagnostic Pearls in Gallstone Ileus

Gallstone ileus is a dramatic complication of gallstone disease, uncommon but not exceptional in a busy emergency department. It represents a cause of mechanical intestinal obstruction, which predominantly occurs in elderly and frail patients; this contributes to the high morbidity and mortality rates associated with this condition. The modern radiologist is frequently asked to determine the cause of bowel obstruction and should be aware of the most pictorial features of this unusual disease. Broadly speaking, abdominal radiography and ultrasonography alone are limited in detecting the cause of bowel obstruction, but the sensitivity for the preoperative diagnosis of gallstone ileus may be improved by combining the findings obtained by both techniques. Computed tomography is the modality of choice for the diagnosis of this disease: it may accurately describe the number, size, and location of migrated gallstones and the exact site of bowel obstruction, providing a detailed preoperative planning. Magnetic resonance imaging may be used in selected cases for an exquisite anatomic definition of the fistulous communication.

The curious case of biliary emesis and bowel obstruction from Bouveret syndrome

Bouveret syndrome is a rare complication of biliary lithiasis. This sequela is caused by the passage of the gallstone via a bilioenteric fistula, resulting in an impacted gallstone in the duodenum or stomach. The common presentation of non-specific symptoms contributes to the diagnostic uncertainty and delay, which is strongly associated with adverse outcomes. We report an uncomplicated stone extraction via open gastrotomy in an elderly man afflicted with bowel obstruction and biliary vomit secondary to Bouveret syndrome.

Clinical and radiological diagnosis of gallstone ileus: a mini review

Gallstone ileus is a rare cause of bowel obstruction, which mainly affects the elderly population. The associated mortality is estimated to be up to 30%. The presentation of gallstone ileus is notoriously non-specific, and this often contributes to the delay in diagnosis. The diagnosis of gallstone ileus relies on a radiological approach, and herein we discuss the benefits and drawbacks of the use of different modalities of radiological imaging: plain abdominal films, computed tomography, magnetic resonance imaging, and ultrasound scanning. Based on our case experience and review of the literature, the authors conclude that although an effective first-line tool, plain abdominal films are not adequate for diagnosing gallstone ileus. In fact, the gold standard in an acutely unwell patient is computed tomography.

Bouveret syndrome, a rare form of gallstone ileus. Case report

Introducción. El síndrome de Bouveret es una entidad poco frecuente de íleo biliar que provoca obstrucción gástrica debido a la presencia de un lito biliar a nivel de píloro o duodeno y secundaria a una fistula biliodigestiva. Esta enfermedad es de difícil diagnóstico y una de sus complicaciones es la hemorragia digestiva alta; su manejo es quirúrgico y se recomienda en dos tiempos, aunque se puede manejar por endoscopia alta en aquellos cálculos <2.5cm. El pronóstico es bueno, con un post-operatorio sin novedades.Presentación del caso. Paciente de 63 años con cuadro clínico de 15 días de evolución de dolor en epigástrico y vómitos biliosos incontables. Se realizaron imágenes diagnósticas donde se evidenció masa calcificada en duodeno II, por lo que la paciente fue intervenida quirúrgicamente: se progresó el cálculo a yeyuno, se realizó enterotomía y se extrajo el lito. Al quinto día fue dada de alta sin novedades.Conclusión. El síndrome de Bouveret es una entidad rara que requiere de una adecuada valoración médica y de métodos auxiliares de imágenes para un diagnóstico oportuno.

Colonic gallstone ileus

Gallstone ileus is a rare aetiology of bowel obstruction and very infrequently occurs in the colon. Typically, colonic gallstone ileus carries a high morbidity and mortality and requires surgery. This case report describes a cholecystocolonic fistula in a patient with ulcerative colitis with resulting colonic gallstone ileus, which was successfully intervened on via an endoscopic approach.

Gallstone Ileus: An Unlikely Cause of Mechanical Small Bowel Obstruction

Gallstone ileus is a rare disease that accounts for 1–4% of intestinal obstructions. Almost exclusively a condition in the older female population, it is a difficult diagnosis to make. We report the case of gallstone ileus in a 94-year-old Caucasian female, who presented to the emergency department with acute-onset nausea, coffee-ground emesis, lack of bowel movement, and abdominal distension. On CT scan, the diagnosis of gallstone ileus was made by the presence of a cholecystoduodenal fistula, pneumobilia, and small bowel obstruction. Emergent laparotomy with a one-stage procedure of enterolithotomy and stone removal by milking the bowel distal to the stone were performed. The postoperative course was uneventful until postoperative day 4 when the patient was found tachycardic, lethargic, and unresponsive. We reviewed the literature on the diagnosis and treatment of gallstone ileus.

Gallstone ileus from a non-calcified stone: a challenging diagnosis

Gallstone ileus is an uncommon and often life-threatening complication of cholelithiasis. In this case, we discuss a difficult diagnostic case of gallstone ileus with a non-calcified gallstone. An 88-year-old female presented with abdominal pain and vomiting. A CT scan was arranged and showed an evolving bowel obstruction although no frank hyperdensity suggestive of a gallstone was noted. Initially the cause of the bowel obstruction was uncertain, but after discussion with the treating team and further review of the images, the patient was diagnosed with gallstone ileus. The patient underwent emergency surgery and a 41 mm obstructing calculus was removed from the patient's jejunum, later confirmed on histological diagnosis.

Pictorial review: the pearls and pitfalls of the radiological manifestations of gallstone ileus

We present a pictorial review of a range of typical and atypical cases of gallstone ileus (GI), across a wide range of imaging modalities. GI is a complication of gallstone disease causing mechanical intestinal obstruction due to impaction of gallstone in the gastrointestinal tract. The spectrum of presentation can vary enormously, and we highlight the importance of accurate imaging diagnosis of GI especially early use of computed tomography. This will lead to timely and appropriate surgical intervention with the potential avoidance of unnecessary outcomes. The ambition of pictorial synopsis is to make the radiologists to be more vigilant to the common and more obscure imaging findings of GI.

Gallstone ileus of the sigmoid colon: an extremely rare cause of large bowel obstruction detected by multiplanar CT

Gallstone ileus of the sigmoid colon is an important, though extremely rare, cause of large bowel obstruction. The gallstone often enters the large bowel through a fistula formation between the gallbladder and colon, and impacts at a point of narrowing, causing large bowel obstruction. We describe the case of an 80-year-old woman who presented with features of bowel obstruction. Multiplanar abdominal CT demonstrated a cholecystocolonic fistula in exquisite detail. The scan also showed obstruction of the colon due to a large gallstone impacted just proximal to a stricture in the sigmoid. Owing to inflammatory adhesions and a stricture from extensive diverticular disease, the gallstone could not be retrieved. This frail and elderly woman was treated with a loop colostomy to relieve bowel obstruction. The patient made an uneventful recovery.

Perforated closed-loop obstruction secondary to gallstone ileus of the transverse colon: a rare entity

Introduction. Gallstone ileus (GSI) of the colon is an extremely rare entity with potentially serious complications including perforation. Case Presentation. An 88-year-old man presented to the emergency department with abdominal pain and distension. Clinical exam revealed signs of peritonism. Computed tomography (CT) revealed GSI of the transverse colon with a closed-loop large bowel obstruction (LBO) and caecal perforation. The patient underwent emergency laparotomy. A right hemicolectomy was performed, the gallstone was removed, and a primary bowel anastomosis was undertaken. A Foley catheter was sutured into the residual gallbladder bed to create a controlled biliary fistula. The patient recovered well postoperatively with no complications. He was discharged home with the Foley catheter in situ. Discussion. Gallstone ileus is a difficult diagnosis both clinically and radiologically with only 50% of cases being diagnosed preoperatively. Most commonly it is associated with impaction at the ileocaecal valve and small bowel obstruction. Gallstone ileus should also be considered as a rare but potential cause of LBO. This is the first reported case of caecal perforation secondary to gallstone ileus of the transverse colon. Successful operative management consisted of a one-stage procedure with right hemicolectomy and formation of a controlled biliary fistula.

Bouveret syndrome: Primary demonstration of cholecystoduodenal fistula on MR and MRCP study

Bouveret syndrome is an unusual complication of cholelithiasis which results in upper gastrointestinal obstruction due to a gallstone impacted in the duodenum through a bilio-enteric fistula. We present this rare entity which was primarily diagnosed on magnetic resonance (MR) and MR cholangiopancreaticography (MRCP) study.

Acute intestinal obstruction due to gallstone ileus

OBJECTIVE

To perform a systematic review of the history, available image exams and clinical approach to the diagnosis and treatment of gallstone ileus.

METHOD

Retrospective study in a university hospital including all cases of SBO treated over a period of 23 years. According to the surgical treatment the patients were divided into two groups: (1) enterolithotomy with cholecystectomy performed later (two-stage surgery); and (2) enterolithotomy, cholecystectomy and fistula closure (one-stage surgery).

RESULTS

Twelve patients were included in the study, including 11 females (91,6%), with a mean age of 72.2 years. All patients presented associated diseases, mainly arterial hypertension (75%). All except one patient had multiple SBO symptoms. Gallstone ileus diagnosis was achieved in six patients (50%) before laparotomy. There were 8 patients in group 1 and 4 in group 2, and the morbidity was, respectively, 33.3% and 8.3%. Overall mortality was 16.6% (one patient in each group).

CONCLUSIONS

Gallstone ileus should be suspected in the elderly with SBO symptoms. Early diagnosis can reduce post-operative complications. Treatment is urgent laparotomy, and surgical treatment must be individualized for each case. The majority of patients in this study were treated with enterolithotomy, with cholecystectomy being performed later in two symptomatic patients.

A case of recurrent gallstone ileus: the fate of the residual gallstone remains unknown

Gallstone ileus is a serious complication of cholelithiasis where mechanical small bowel obstruction occurs. The recurrence of gallstone ileus is rare. The 67-year-old woman in this case report had three known gallstones transit her small bowel with two causing obstruction and the third causing a 'tumbling phenomenon'. As we have an ageing population, and gallstone ileus has a higher incidence in the over 65 age group, associated with increased comorbidities and hence greater mortality rates, it is imperative to establish the best surgical intervention for it. This case report highlights the difference CT of the abdomen has made to the diagnosis of gallstone ileus and the pros and cons of the surgical management options.

Usefulness of CT-scan in the diagnosis and therapeutic approach of gallstone ileus: report of two surgically treated cases

Background

Gallstone ileus is a rare cause of gastrointestinal obstruction, more frequent in elderly patients, whose treatment is essentially surgical, although some para-surgical and mini-invasive possibilities exist, allowing the solution of such obstructive condition in a completely non-invasive way.

Description

In our study, after reporting two cases of biliary ileus managed by our surgical division, we will analyze the most suitable diagnostic procedures and the therapeutic approaches to this pathology.

Conclusions

Gallstone ileus is a quite rare pathology in population, but affects more frequently elderly people; The treatment of this disease is mainly surgical.

[Gallstone ileus as a cause of acute abdomen. Importance of early diagnosis for surgical treatment]

Gallstone ileus is an uncommon type of mechanical intestinal obstruction caused by an intraluminal gallstone, and preoperative diagnosis is difficult in the Emergency department. This study is a retrospective analysis of the clinical presentation of 5 patients with gallstone ileus treated between 2000-2010. Clinical features, diagnostic testing, and surgical treatment were analyzed. Five patients were included: 2 cases showed bowel obstruction; 2 patients presented a recurrent gallstone ileus with prior surgical intervention; and one patient presented acute peritonitis due to perforation of an ileal diverticula. In all cases CT confirmed the preoperative diagnosis. In our experience, gallstone ileus may present with clinical features other than intestinal obstruction. In suspicious cases CT may be useful to decrease diagnostic delay, which is associated with more complications.

Bouveret's syndrome: presentation of two cases with review of the literature and development of a surgical treatment strategy

BACKGROUND

Bouveret's syndrome causes gastric outlet obstruction when a gallstone is impacted in the duodenum or stomach via a bilioenteric fistula. It is a rare condition that causes significant morbidity and mortality and often occurs in the elderly with significant comorbidities. Individual diagnostic and treatment strategies are required for optimal management and outcome. The purpose of this paper is to develop a surgical strategy for optimized individual treatment of Bouveret's syndrome based on the available literature and motivated by our own experience.

CASE PRESENTATION

Two cases of Bouveret's syndrome are presented with individual management and restrictive surgical approaches tailored to the condition of the patients and intraoperative findings.

CONCLUSIONS

Improved diagnostics and restrictive individual surgical approaches have shown to lower the mortality rates of Bouveret's syndrome. For optimized outcome of the individual patient: The medical and perioperative management and time of surgery are tailored to the condition of the patient. CT-scan is most often required to secure the diagnosis. The surgical approach includes enterolithotomy alone or in combination with simultaneous or subsequent cholecystectomy and fistula repair. Lower overall morbidity and mortality are in favor of restrictive surgical approaches. The surgical strategy is adapted to the intraoperative findings and to the risk for secondary complications vs. the age and comorbidities of the patient.

Gallstone ileus of the colon: leave no stone unturned

A case of gallstone ileus of the colon with illustrative pictures is presented, making the physicians more aware of this rare entity. Furthermore, the use of imaging modalities for diagnosis and decision making in management strategy is discussed.

Gallstone ileus and jejunal perforation along with gangrenous bowel in a young patient: A case report

Context:

Gallstone ileus is an uncommon condition with potentially serious complications including perforation and gangrene of the small bowel. Its diagnosis is difficult and surgery remains the mainstay of treatment. Here we are reporting the complications of this condition along with brief review of literature.

Case Report:

We report a case of intestinal obstruction due to gallstone in the small gut which was diagnosed preoperatively on ultrasonography and confirmed on exploratory laparotomy. Postoperative period was uneventful.

Conclusion:

Gallstone ileus is a rare cause of intestinal obstruction and it should be considered in patients who are suffering from gallstone disease and presenting with intestinal obstruction especially when no other obvious cause is seen.

A case of gallstone ileus displaying spontaneous closure of cholecystoduodenal fistula after enterolithotomy

INTRODUCTION

Gallstone ileus, a rare complication of cholelithiasis and cholecystitis, is a relatively rare cause of alimentary tract obstruction. It is usually associated with a cholecystoenteric fistula through which a gallstone has passed into the gastrointestinal tract. Cholecystoenteric fistula uncommonly closes spontaneously, the period between formation and closure having rarely been reported. In addition, endoscopic detection of cholecystoenteric fistulous closure has seldom been reported.

PRESENTATION OF CASE

We report a 51-year-old Japanese man with gallstone ileus in whom spontaneous closure of a cholecystoduodenal fistula was observed by endoscopy 2 weeks after laparoscopy-assisted enterolithotomy.

DISCUSSION

Laparoscopy-assisted enterolithotomy for gallstone ileus allows direct diagnosis of gallstone ileus and assessment of the status of adhesions affecting the biliary tract.

CONCLUSION

Endoscopic confirmation of fistulous closure after laparoscopy-assisted enterolithotomy is a minimally invasive approach that may avert the need for biliary surgery.

[A case of gallstone ileus treated with electrohydraulic lithotripsy guided by colonoscopy]

A 63-year-old woman was admitted to the hospital with abdominal pain and nausea. Her abdomen was distended with obstructive bowel sounds on exam. There was diffuse abdominal tenderness but no palpable masses. Abdominal computed tomography (CT) scan revealed a large gallstone in the ileum. Surgical intervention was deferred given patient's known significant liver cirrhosis (Child-Pugh class B). Instead colonoscopy was performed and a large gallstone was found to be impacted at the ileocecal valve. The gallstone was fragmented using electrohydraulic lithotripsy (EHL) and then retrieved with snare and forceps. The patient made a full recovery and was eventually discharged home. This is the first reported case of an impacted gallstone at the ileocecal valve with successful colonoscopic treatment using electrohydraulic lithotripsy in Korea. This case highlights the potential therapeutic benefits for colonscopic retrieval of a gallstone impacted at the ileocecal valve in well selected individuals.

Gallstone ileus: correlation between computed tomography, double-balloon enteroscopy and intra-operative findings

Gallstone ileus is an uncommon cause of small bowel obstruction, affecting mainly elderly patients. We report a case of gallstone ileus in an 88-year old female patient. The correlation between computed tomography, double-balloon enteroscopy and intra-operative findings is discussed, as well as treatment strategies.

A rare variant of gallstone ileus: Bouveret's syndrome

INTRODUCTION

Bouveret's syndrome (gastric outlet obstruction due to impaction of a stone) is a rare variant of gallstone ileus. A recently observed case led us to review the literature, with the aim to discuss the recent advances in the management of this rare syndrome.

DISCUSSION

A 69-year-old woman was admitted with symptoms of high intestinal obstruction. Computed tomography scan of the abdomen showed a large gallstone impacted in the duodenum. One-stage surgery, consisting in enterolithotomy, cholecystectomy, and fistula repair, was carried out. Although several surgical and nonoperative procedures have been used, the optimal treatment of Bouveret's syndrome remains controversial. Surgery still maintains a prominent position, even though nonoperative procedures have an increasing role especially in high risk patients with important comorbidities. The decision should be taken on an individual basis, after evaluating patient's general condition and age, stone size, comorbidities influencing the operative risk, and expertise of surgical and endoscopic teams. One-stage surgery may offer definitive management in selected patients.

A rare variant of gallstone ileus: Bouveret's syndrome

INTRODUCTION

Bouveret's syndrome (gastric outlet obstruction due to impaction of a stone) is a rare variant of gallstone ileus. A recently observed case led us to review the literature, with the aim to discuss the recent advances in the management of this rare syndrome.

DISCUSSION

A 69-year-old woman was admitted with symptoms of high intestinal obstruction. Computed tomography scan of the abdomen showed a large gallstone impacted in the duodenum. One-stage surgery, consisting in enterolithotomy, cholecystectomy, and fistula repair, was carried out. Although several surgical and nonoperative procedures have been used, the optimal treatment of Bouveret's syndrome remains controversial. Surgery still maintains a prominent position, even though nonoperative procedures have an increasing role especially in high risk patients with important comorbidities. The decision should be taken on an individual basis, after evaluating patient's general condition and age, stone size, comorbidities influencing the operative risk, and expertise of surgical and endoscopic teams. One-stage surgery may offer definitive management in selected patients.

Cholecystostomy does not prevent gallstone ileus: a case report

Introduction

Gallstone ileus following cholecystostomy has been reported once, in a patient with acute cholecystitis, where symptoms of small intestinal obstruction had developed one day after surgery. We report a case of gallstone ileus eight months following a cholecystostomy, which might deter the diagnosis. This is the only such reported case in medical literature according to our knowledge.

Case presentation

A 54-year-old Sri Lankan female with a past history of a cholecystostomy presented with symptoms suggestive of small intestinal obstruction. Evidence of ileal obstruction with pneumobilia in the supine radiograph of the abdomen and cholecyto-duodenal fistula in the water soluble contrast study was suggestive of the diagnosis of gallstone ileus. An enterolithotomy was performed with no attempt of closure of the cholecysto-duodenal fistula.

Conclusion

This case demonstrates the value of the supine radiograph of the abdomen and the barium follow-through in diagnosis. A cholecystogram, preferably preoperative, is the mainstay of prevention and identification of this clinical scenario.

Migrating intrathoracic gallstone: imaging findings

We present the case of a 76-year-old man referred to our hospital with a round stone in central mediastinum and pneumomediastinum in chest radiography and computed tomography. He had a previous history of attempt of endoscopic retrievement of a gallstone that had caused a gastric outlet obstruction (Bouveret syndrome). To our knowledge, this is the first imaging description of mediastinal gallstone caused by esophagus perforation during complicated endoscopic lithotomy.

Gallstone ileus: surgical strategies and clinical outcome

OBJECTIVE

Gallstone ileus is a rare cause of intestinal obstruction affecting mainly the elderly. This study aimed to analyze the surgical treatments and outcome of the disease.

METHODS

We present a retrospective study of 13 patients diagnosed with gallstone ileus from January 2000 to December 2005 in our hospital and a review of the published literature.

RESULTS

Three men and 10 women participated in the study, with a mean age of 74.3 (range: 63-85). The mean duration of symptoms was 6 days (range 2-14). A pre operative diagnosis was made in 10 patients. The mean delay in diagnosis was 3.5 days (range 1-10). Ten patients had an enterolithotomy (E) and three patients had a one-stage procedure comprising enterolithotomy, cholecystectomy and fistula repair (EC). There was no postoperative mortality in either group. The mean postoperative hospital stay for group E was 14 (range 6-31) days and for group EC was 19 (range: 5-28) days. Twelve patients were alive at the time of review. One patient from group E died of unrelated causes after three years. One patient in group E developed cholangitis but no surgical intervention was required on case note review over a mean postoperative period of 3.4 years.

CONCLUSION

E alone is best suited in all elderly gallstone ileus patients with significant comorbidities. A one-stage procedure (EC) should be reserved for young, fit and low risk patients.

Jejunal perforation in gallstone ileus - a case series

Introduction

Gallstone ileus is an uncommon complication of cholelithiasis but an established cause of mechanical bowel obstruction in the elderly. Perforation of the small intestine proximal to the obstructing gallstone is rare, and only a handful of cases have been reported. We present two cases of perforation of the jejunum in gallstone ileus, and remarkably in one case, the gallstone ileus caused perforation of a jejunal diverticulum and is to the best of our knowledge the first such case to be described.

Case presentations

Case 1

A 69 year old man presented with two days of vomiting and central abdominal pain. He underwent laparotomy for small bowel obstruction and was found to have a gallstone obstructing the mid-ileum. There was a 2 mm perforation in the anti-mesenteric border of the dilated proximal jejunum. The gallstone was removed and the perforated segment of jejunum was resected.

Case 2

A 68 year old man presented with a four day history of vomiting and central abdominal pain. Chest and abdominal radiography were unremarkable however a subsequent CT scan of the abdomen showed aerobilia. At laparotomy his distal ileum was found to be obstructed by an impacted gallstone and there was a perforated diverticulum on the mesenteric surface of the mid-jejunum. An enterolithotomy and resection of the perforated small bowel was performed.

Conclusion

Gallstone ileus remains a diagnostic challenge despite advances in imaging techniques, and pre-operative diagnosis is often delayed. Partly due to the elderly population it affects, gallstone ileus continues to have both high morbidity and mortality rates. On reviewing the literature, the most appropriate surgical intervention remains unclear.

Jejunal perforation in gallstone ileus is extremely rare. The cases described illustrate two quite different causes of perforation complicating gallstone ileus. In the first case, perforation was probably due to pressure necrosis caused by the gallstone. The second case was complicated by the presence of a perforated jejunal diverticulum, which was likely to have been secondary to the increased intra-luminal pressure proximal to the obstructing gallstone.

These cases should raise awareness of the complications associated with both gallstone ileus, and small bowel diverticula.

Bouveret syndrome and gallstone ileus

Intestinal obstruction from gallstones is a rare complication of gallstone disease. These ectopic gallstones can cause obstruction anywhere from the duodenum to the colon and are accompanied by a cholecystoduodenal/enteric/colic fistula. We report an 81-year-old male who presented with gallstone obstruction of the duodenum who underwent attempted endoscopic fragmentation and extraction that eventually led to small bowel obstruction from an impacted fragment of the stone. He underwent successful enterolithotomy and has been asymptomatic from the cholecystoduodenal fistula. Surgery is the gold standard for the treatment of this condition but the extent of the operation remains a matter of debate.

Gallstone Ileus: Diagnosis and Management

BACKGROUND

Gallstone ileus is a rare complication of cholelithiasis, mostly in the elderly. It accounts for 1%-4% of mechanical bowel obstruction and is associated with high morbidity and mortality. We present our experience of gallstone ileus and discuss current opinion as reported in the literature.

PATIENTS AND METHODS

A retrospective review was performed of medical records of patients in our institution coded for gallstone ileus by the International Classification of Diseases (ICD K-563) coding system between January 1998 and December 2005.

RESULTS

There were 22 patients with mean age of 77 (58-92) years and a female to male ratio of 4.5:1. Most patients presented with abdominal pain and vomiting, with a median duration of symptoms of 3 (1-28) days. Preoperative diagnosis was made in 77% from a combination of plain x-ray, ultrasonography, and computed tomography (CT) scans; 86.4% of the patients belonged to ASA class of 3 or 4. Twenty patients underwent enterolithotomy alone, and two had one-stage procedure. The mean size of impacted stones was 3.6 (2.5-4.5) cm, with location in the terminal ileum in 17 and jejunum in 5 patients. There were 5 perioperative deaths and an episode of cholangitis occurring in one patient 18 months after enterolithotomy alone.

CONCLUSIONS

Gallstone ileus is a difficult clinical entity to diagnose. Unreserved use of imaging techniques can improve diagnostic accuracy and speed of therapeutic decision making. Management of gallstone ileus must be individualized. The one-stage procedure should be offered only to highly selected patients with good cardiorespiratory reserve and with absolute indications for biliary surgery at the time of presentation.

Gallstone ileus: Report of two cases and review of the literature

Gallstone ileus is a rare disease and accounts for 1%-4% of all cases of mechanical intestinal obstruction. It usually occurs in the elderly with a female predominance and may result in a high mortality rate. Its diagnosis is difficult and early diagnosis could reduce the mortality. Surgery remains the mainstay of treatment. We report two cases of gallstone ileus. The first was a 78-year old woman who had a 2-d history of vomiting and epigastralgia. Plain abdominal film suggested small bowel obstruction clinically attributed to adhesions. Later on, gallstone ileus was diagnosed by abdominal computed tomography (CT) based on the presence of pneumobilia, bowel obstruction, and an ectopic stone within the jejunum. She underwent emergent laparotomy with a one-stage procedure of enterolithotomy, cholecystectomy and fistula repair. The second case was a 76-year old man with a 1-wk history of epigastralgia. Plain abdominal film showed two round calcified stones in the right upper quadrant. Fistulography confirmed the presence of a cholecystoduodenal fistula and gallstone ileus was also diagnosed by abdominal CT. We attempted to remove the stones endoscopically, but failed leading to an emergent laparotomy and the same one-stage procedure as for the first case. The postoperative courses of the two cases were uneventful. Inspired by these 2 cases we reviewed the literature on the cause, diagnosis and treatment of gallstone ileus.

Endoscopic drainage of empyema of the gallbladder through a concurrent cholecystoduodenal fistula

The duodenum is the most common site of cholecystoenteric fistulation resulting from cholecystitis or empyema of the gallbladder. This rare condition is usually only diagnosed intraoperatively and managed incidentally. This paper presents the endoscopic diagnosis of a case of cholecystoduodenal fistula arising from the late presentation of empyema of the gallbladder and its subsequent drainage through the fistula. As far as we can determine, this is the only reported case of opportunistic drainage of an empyema of the gallbladder through a concurrent cholecystoduodenal fistula.

Laparoscopic Management of Gallstone Presenting as Obstructive Gangrenous Appendicitis

We present an unusual case of a 55-year-old man with symptoms of recurrent appendicitis. Laparoscopy revealed a 1.5 cm gallstone impacted at the base of the appendix, leading to gangrenous appendicitis. This patient did not have any features of gallstone ileus. On imaging he had an inflammatory mass in the region of the right iliac fossa with a hyperintense shadow in the cecal area which was reported as an appendicolith. There was no demonstrable cholelithiasis or biliary-enteric fistula. There were dense omental adhesions in the pericholecystic area on laparoscopy. The case was successfully managed by laparoscopic appendectomy with retrieval of the gallstone. No surgery was undertaken for the gallbladder. Diagnosis was confirmed by biochemical analysis of the stone, which contained calcium bilirubinate and cholesterol. A gallstone obstructing the appendicular lumen is a very rare etiology of gangrenous perforation of the appendix peritonitis. This case was successfully managed laparoscopically.

Value of CT in the diagnosis and management of gallstone ileus

AIM: To retrospectively establish the diagnostic criteria of gallstone ileus on CT, and to prospectively apply these criteria to determine the diagnostic accuracy of CT to confirm or exclude gallstone ileus in patients who presented with acute small bowel obstruction (SBO). Another purpose was to ascertain whether the size of ectopic gallstones would affect treatment strategy.

METHODS: Fourteen CT scans in cases of proved gallstone ileus were evaluated retrospectively by two radiologists for the presence or absence of previously reported CT findings to establish the diagnostic criteria. These criteria were applied in a prospective contrast enhanced CT study of 165 patients with acute SBO, which included those 14 cases of gallstone ileus. The hard copy images of 165 CT studies were reviewed by a different group of two radiologists but without previous knowledge of the patient’s final diagnosis. All CT data were further analyzed to determine the diagnostic accuracy of gallstone ileus when using CT in prospective evaluation of acute SBO. The size of ectopic gallstone on CT was correlated with the clinical course.

RESULTS: The diagnostic criteria of gallstone ileus on CT were established retrospectively, which included: (1) SBO; (2) ectopic gallstone; either rim-calcified or total-calcified; (3) abnormal gall bladder with complete air collection, presence of air-fluid level, or fluid accumulation with irregular wall. Prospectively, CT confirmed the diagnosis in 13 cases of gallstone ileus with these three criteria. Only one false negative case could be identified. The remaining 151 patients are true negative cases and no false positive case could be disclosed. The overall sensitivity, specificity and accuracy of CT in diagnosing gallstone ileus were 93%, 100%; and 99%, respectively. Surgical exploration was performed in 13 patients of gallstone ileus with ectopic stones sized larger than 3 cm. One patient recovered uneventfully following conservative treatment with an ectopic stone sized 2 cm in the long axis.

CONCLUSION: Contrast enhanced CT imaging offered crucial evidence not only for the diagnosis of gallstone ileus but also for decision making in management strategy.