Gall stone ileus: Unfamiliar cause of bowel obstruction. Case report and literature review

Abstract

Introduction: Gallstone ileus is a rare sequela of cholelithiasis. The pathology occurs as a result of bilioenteric fistula due to erosion by the offending gallbladder stone. It is most commonly encountered in elderly females and CT imaging is diagnostic in the majority of cases. Surgical intervention aims to promptly relief the obstruction by removing the gallstone and dealing with the fistula. Morbidity and mortality are usually high since it usually occurs in elderly patients.

Presentation of case: An 88-year-old lady with multiple chronic medical problems and no history of biliary manifestation presented with acute small bowel obstruction. Abdominal CT imaging revealed a bilioenteric fistula and an impacted gallstone in the jejunum causing occlusion. Laparotomy was performed and the stone was removed via enterolithotomy. Manipulation of the cholecystoduodenal fistula was not attempted due to severe inflammatory adhesions. The patient had uneventiful postoperative course and remained symptom free on one year follow-up.

Discussion and conclusion: Management of gallstone ileus is mainly surgical. Delay in detection and treatment of gallstone ileus may result in significant morbidity and mortality. The choice of surgical option is influenced by the preoperative medical status of the patient. A literature review generally supports the employment of enterolithotomy in high-risk patients and reserving cholecystectomy and resection of the fistula for less comorbid patients with feasible anatomy.

Keywords: Case report; Cholecystoduodenal fistula; Enterotomy; Gallbladder stones; Gallstone ileus; Intestinal obstruction.

Fig. 1

Dilatation of the biliary system including the intrahepatic ducts with coexisting pneumobilia, cholecystoduodenal fistulization can be appreciated with contracted irregular gallbladder outline containing air locules extending to the juxtapositioned duodenal lumen with a heterogenous enhancement at the site of the abnormal communication.

Fig. 2

Ectopically positioned hyperdense luminal structure, measuring about 3.5 × 3 cm in caliber at the sentinel jejunal segment suggestive of a gallstone resulting in distended small bowel dilataion with adjacent collapsed small and large bowel loops.

Fig. 3

Gallbladder stone impacted in a jejunal loop measuring about 3.5 × 3 cm.