Gallstone ileus

Gallstone ileus is a rare form of small bowel obstruction caused by an impaction of a gallstone within the lumen of the small intestine. Such a gallstone enters the bowel via a cholecysto-enteric fistula. The presence of large stones, >2.5 cm in diameter, within the gallbladder are thought to predispose to fistula formation by gradual erosion through the gallbladder fundus.[1] Once a fistula has formed, a stone may travel from the gallbladder into the bowel and become lodged almost anywhere along the gastrointestinal tract. Obstruction occurs most commonly at the near the distal ileum, within 60 cm proximally to the ileocecal valve.[2][3] Rarely, gallstone ileus may recur if the underlying fistula is not treated.[4]

Gallstone ileus
SpecialtyGastroenterology

First described by Thomas Bartholin in 1654, the name "gallstone ileus" is a misnomer because an ileus is, by definition, a non-mechanical bowel motility failure (as opposed to a mechanical obstruction by a stone). Mortality rate is as high as 80 percent, with males under 50 years old known to be 96 to 98.4 percent.

Diagnosis

Diagnosis of gallstone ileus requires radiographic studies. Classic radiographic findings are known as Rigler's triad:[5]

Treatment

Initial management involves fluid resuscitation and potentially nasogastric suctioning.[1] Since gallstone ileus constitutes a form of mechanical small bowel obstruction, it can be a surgical emergency and requires open or laparoscopic surgery to remove an impacted stone.[1] The different strategies for surgical management are either enterolithotomy alone, allowing a delayed cholecystectomy after an inflammation-free period of 4–6 weeks (and therefore two-stage surgery) or enterolithotomy in combination with a cholecystectomy and fistula division (one-stage surgery). The different strategies for surgical management are controversial, and depend on factors such as patient fitness for surgery and comorbidities. Mortality rates are reported to be 80 percent, and in some cases with men under 50 reported at 97 to 98.4 percent.[4]

Eponym

Bouveret's syndrome refers to reverse gallstone ileus where the gallstone propagates proximally and causes gastric outlet obstruction by being impacted in first part of duodenum.

References
  1. Longo, DL; Fauci, AS; Kasper, DL; Hauser, SL; Jameson, JL; Loscalzo, J (2015). Harrison's Principles of Internal Medicine (19 ed.). New York: McGraw-Hill. pp. 2081–2082. ISBN 978-0-07-180216-1. Retrieved 3 March 2017.
  2. Gaillard, Frank. "Gallstone Ileus". Radiopaedia. Retrieved 17 December 2013.
  3. Williams, N.; O'Connell, P. R., eds. (2013). Bailey & Love's Short Practice of Surgery (26th ed.). CRC Press. ISBN 978-1444121278.
  4. Fitzgerald J, Fitzgerald L, Maxwell-Armstrong C, Brooks A (2009). "Recurrent gallstone ileus: time to change our surgery?". Journal of Digestive Diseases. 10 (2): 149–151. doi:10.1111/j.1751-2980.2009.00378.x. PMID 19426399.
  5. Ibrahim, Dalia; Gaillard, Frank. "Rigler's Triad". Radiopaedia. Retrieved 17 December 2013.
Classification
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