Gallstone Ileus: Management and Clinical Outcomes

Abstract

Background: Gallstone or biliary ileus is a late complication of gallstone disease. It accounts for 1%-4% of all bowel obstructions and is more common in elderly patients. The preferred treatment option is to mechanically remove the impacted stones. It is done surgically using open or laparoscopic approach and rarely, when stones are impacted in the colon, endoscopically. In this paper we present five consecutive cases of gallstone ileus and describe possible diagnostic and minimally invasive treatment options. Case presentation: During a five-month period a total of five patients were treated for gallstone ileus. All patients were female and from 48 to 87 years of age. Symptoms were not specific and common for all small bowel obstructions. Upon admission the patients also had unspecific laboratory findings-neutrophilic leukocytosis and various C-reactive protein concentrations, ranging from 8 to 347 mg/L. According to the hospital protocol, all patients initially underwent an abdominal ultrasound, which was inconclusive, and therefore every patient additionally had a CT scan with intravenous contrast. After these two diagnostic modalities one patient still did not have the definitive gallstone ileus diagnosis, as the ectopic stone was not visible. Four patients in our case series were treated using minimally invasive methods: in one case the stone was removed endoscopically, and laparoscopically in the other three. Treatment outcomes were good in four cases as the patients fully recovered, however one patient suffered a massive cerebral infarction after the operation and passed away. Conclusions: Gallstone ileus is a rare and difficult-to-diagnose condition. Management of these patients in every case should be individualized, as there are many options, each with their own advantages and disadvantages. We show that minimally invasive treatment such as colonoscopy or laparoscopy is possible in these cases.

Keywords: biliary ileus; diagnosis; endoscopy; gallstone; laparoscopy; treatment.

Figure 1

82-year-old female. Abdominal CT scan, coronal plane, portovenous phase. The transition point of the obstruction is visible, the gall stone is obstructing the small bowel lumen (arrow), distal loops are collapsed.

Figure 2

69-year-old female. Abdominal CT scan, sagittal plane, portovenous phase. Collapsed gallbladder (asterisk), there is a defect in the wall connecting the lumen of the gall bladder with the lumen of hepatic flexure of the colon–cholecystocolic fistula (arrow).

Figure 3

69-year-old female. Abdominal CT scan, axial plane, portovenous phase. The gallstone that migrated through cholecystocolic fistula is obstructing the lumen of sigma (arrow).

Figure 4

87-year-old female. Abdominal CT scan, axial plane, portovenous phase. Collapsed gallbladder, with thickened walls, pericholecystitis and air in the pericholecystic space. Also, a connecting path between the gallbladder and duodenum is visible (arrow)—cholecystoduodenal fistula.

Figure 5

87-year-old female. Abdominal CT scan, coronal plane, portovenous phase. Dilated segment of proximal jejunal loops (thin arrow) caused by migrated gallstone (thick arrow) obstruction. Distal to the gallstone, jejunal loops are collapsed.

Figure 6

A 3 × 4 cm gallstone in the ileum, removed through a McBurney incision.

Figure 7

A 4 × 3 cm gallstone removed during laparoscopically assisted enterolithotomy.

Figure 8

Impacted gallstone in the sigmoid colon successfully removed during colonoscopy.