Gallstone Ileus

Gallstone Ileus is an infrequent cause of mechanical bowel obstruction. It is caused by an impaction of a gallstone in the terminal ileum by passing through a billiary-enteric fistula (often from duodenum). It occurs more frequently in women with average age of 70 years.

Clinical picture: Episodic subacute obstruction in an elderly female. Abdominal pain and vomiting which subside as the gallstone becomes disimpacted, and only recurs again as the progressively larger stone lodges in the more distal bowel lumen. Intermittent symptoms may be present for some days prior to evaluation. Hematemesis could occur as an occasional complication that is due to hemorrhage at the site of the biliary enteric fistula.

Physical examination: The patient may be febrile and often appears dehydrated. Common abdominal signs include distension and increased bowel sounds. Jaundice is uncommon, occurring in less than 15% of cases. Many affected patients have serious concomitant medical illnesses, including coronary disease, diabetes mellitus or pulmonary disease.

Diagnosis: The most important diagnostic test is abdominal plain film. The diagnosis of gallstone ileus is made preoperatively in about one-half of cases. The radiographig findings of gallstone ileus, are:

  • Signs of partial or complete intestinal obstruction
  • Air in the biliary tree (pneumobilia)
  • Direct visualization of the stone
  • Change in position of a previously located stone
  • Two adjacent small bowel air-fluid levels in the right upper quadrant

Treatment: First of all, as any kind of bowel obstruction, the objective is to relief intestinal obstruction after adequate fluid repletion. The options are enterolithotomy, cholecystectomy, and fistula division, with or without common bile duct exploration (one-stage procedure), with definitive repair performed at a second operation (two-stage procedure).
The treatment of choice is the enterolithotomy wich consits in localize and extract the gallstone. Often the cholecystectomy is contraindicated by comorbidities and the general state of the patient.

Case presentation: A 72 year old woman with heart faliure, hypertension and diabetes came to the office with a chief complaint of chills, abdominal pain, nausea and vomiting followed by inability to pass flatus 8 hours prior to consult.

On physical examination the patient was febrile and appeared dehydrated. Abdominal exam: distension and increased bowel sounds. No jaundice.

Labs: Hyperglicemia, mild renal failure, hypernatremia and leukocytosis.

Radiographic tests: Abdominal plain film with signs of bowel obstruction and with not apparent cause, negative US. CT scan just with signs of intestinal obstruction, not pneumobilia, not obstructing gallstones.

The patient bacame hemodinamically unstable while performing the US and we decided to open her. On the OR we found the level of obstruction at terminal ileum and we felt a solid mass. We performed an enterolithotomy and the result was this:

Gallstone Ileus

Regards,

Dr. Jon Mikel Iñarritu

15 thoughts on “Gallstone Ileus

  1. Hamburger Helper

    Don’t know if you’re still on here, but we had a case like this the other night. Thanks for the insight. One of our docs diagnosed it from the X-rays and she was right.

  2. marty mcgrail

    Approx. one month ago I thought I had food poisoning 4 to 6 hours after eating claims. I vomited several times in the middle of the night and was sick with low grade fever for 3 days. I had a feeling like I was punched in the right side, lots of gas and very dark stools for two days. It passed. Went for a MRI w/contrast and a large calcified stone was identified measuring approx 2 cm. The report states there is no intrahepatic or extrahepatic biliary ductal dilation and the pancreatic duct is normal in caliber. The liver is normal in size and signal intensity but there is minimal loss of signal intensity on out-of-phase imagining consistent with fatty infiltration. My blood-work reviels a Amylase, derum reading of 116 out of a range of 0 – 99. I visited a surgeon and he wants to remove my gallbladder stating should I be in a flying or in the mission field I may suffer an attack which could kill me. I must admit, I would do anything to avoid surgery, do you find surgery is a must? Thanking you. – mdm

  3. Jon Mikel Iñarritu Post author

    Maria,

    Thank you so much for kindly sharing your story; this is exactly an alert to the readers of this site.

    When I see a patient with history of vomiting and the physical exam reveals a disteded abdomen I routinely order plain abdominal films (x rays) among other things.

    The work-up is crucial in this condition.

    I hope you are doing well!

    Best of all,

    Jon Mikel Iñarritu-Castro

  4. Maria

    Dear Dr. Iñarritu,

    I found this page while looking for information on gallstone ileus. I’m 64 and had laparoscopic surgery three weeks ago to remove the obstruction, a largish gallstone “lodged where the small intestine joins the colon” (my dorctor’s explanation) The gallbladder was not removed or the fistula fixed because the area was still inflammed, and I was acutely debilitated and dehydrated after four days of constant vomiting.

    I’m recovering quite well, able to eat normally etc. and feel generally good. I will go for a follow-up check in a couple of days and at that point, the doctor may (or not) contemplate further surgery to remove the gallbladder. We’ll see.

    Mainly I wanted to alert your readers to one curious fact. During the four days of miserable and constant vomiting, I went twice to my local Urgent Care clinic. The doctors who saw me thought I was suffering from either food poisoning or a 24-hour stomach flu, and did not suspect anything worse because I HAD NO PAIN AT ALL. They gave me one liter of saline intravenously each time and sent me home with prescriptions for anti-nausea and anti-acid reflux medicines. On the fourth day, my dehydration was so acute my kidneys shut down and my blood pressure plummetted, I lost consciousness and was admitted via ambulance to the hospital. There, after two days of resuscitation and tests, the obstruction was diagnosed and surgery performed. The surgeon was also puzzled at the LACK OF PAIN, but there you have it…it happens.

    So, because I felt no pain anywhere, the doctors at the Urgent Care facility did not recognize the possibility of a gallstone obstruction. Please alert your readers to the fact that absence of pain does not necessarily rule out something as serious as gallstone ileus, and that uncontrollable vomiting calls for prompt attention…at a hospital! I wasted four days!

    Thanks you
    Maria

  5. anon

    Hi,
    i was recently hospitalized for gallstones, this is the first time i’ve had them, they did an ultrasound scan and it was discovered that there were 2 small stones but they were no longer in my gallbladder, I still feel sick after eating and still have ‘some’ pain, i wanted to ask how long the stones take to pass and how likely is it that they will recur and how soon as the Doctors told me that they will probably remove the gallbladder if it happens again

  6. Jon Mikel Iñarritu Post author

    Marivic Muñoz,

    You don’t provide us any information of what part of the intestine was removed. But any type of intestine resection may lead to intestinal obstruction (stenosis).

  7. Marivic Munoz

    Hi:
    My mother had a surgery a week ago, she had acute gallstone.
    It had a complications in her small intestines that the surgeons cut part of her small intestines because of the presence of stones, they mention that the her case was severe and they don’t promise anything. A week into the surgery she started vomiting after she was given water and light meal. She vomits a lot of smelly blood and everything that she had taken in. Three consecutive x-rays were done and the doctors said that she needs another surgery because it looks like that the intestines stuck together causing obstrution of whatever she takes in. Can I get your opinion in this case.
    Thank you

  8. linda-lou

    Hi Dr. Mikel,
    I found you from “Change of Shift”. I really enjoyed your case presentation- especially the images. I can’t wait to see what else your blog has to offer :)

  9. JonMikel, M.D. Post author

    intelinurse:

    Gallstone ileus is a complication of biliary enteric fistula (wich complicates 2% to 3% of all cases of cholelitiasis).

    So it takes a long to have this condition.

    Once patients have a gallstone in their bowel, the mean symptom duration before hospital admission is approximately 5 days.

    Regarding to its size, 90% of obstructing gallstones are greater than 2 cm in diameter, with the majority measuring over 2.5 cm.

    Thanks for visiting. I’ll be waiting for the next edition of the Nursing Blog Carnival you are going to host on next week.

  10. JonMikel, M.D. Post author

    Cathy:

    I’m not on blogtastic. Unbounded Medicine is hosted by me.

    My principal issue is the lack of comments I get some hits and pageviews everyday, but I don’t get comments.

    Thanks for your visit (and your comment)

  11. intelinurse2b

    Ouch!

    How long does it take for something like to form? And at what size does it become when it prevents the passage of stool around it and blocks stool motility altogether?

  12. Cathy

    Hi Dr. Mikel….I just saw your comment over at Dr. A.s…..I wanted to ask you if you were on blogtastic? The reason I ask is that I have a blog on blogger that gets quite a few hits a day. In addition I created one at blogtastic that I only use to transfer some of my work from blogger to. I do that in case blogger, with it’s many problems, goes down I will have part of my work saved on another hosting site. I have found, after months, that my blog on blogtastic has not EVER had even one visitor. I don’t promote it in any way but still it seems amazing that not one person has visited it. For some reason I can only imagine that blogtastic is not tied into any of the other hostings and I don’t see a “Next blog” button which is where I initailly got alot of my first time visitors on blogger.

    That may be one reason why it has been slow for you getting readers. I think your site is great and I think you just have to keep visiting and leaving comments on other blogs. People will find you that way and before long you will become quite popular.

    That was just some thoughts I had…

    Have a great weekend!

    Cathy

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