Gallstone ileus: What to do, when, and why: A case-based review of surgical options

Abstract

Introduction: Gallstone ileus (GI) is a rare and serious complication of cholelithiasis, causing intestinal obstruction due to the migration of gallstones into the bowel lumen. It predominantly affects elderly patients and often lacks specific symptoms, delaying diagnosis and increasing mortality.

Case presentation: We report a case of a 60-year-old male with signs of small bowel obstruction and a known history of gallstones. CT imaging confirmed a large gallstone impacted in the distal ileum. The patient underwent exploratory laparotomy with distal enterotomy and stone extraction, followed by an uneventful recovery.

Discussion: This case illustrates the decision-making process in choosing between enterolithotomy, one-stage, and two-stage surgical approaches. A distal enterotomy was selected based on intraoperative anatomy, as the distal bowel was decompressed and healthier. Simultaneous cholecystectomy and fistula repair were deferred due to the patient's frailty, consistent with a two-stage strategy. A comprehensive literature review is provided to guide operative decision-making in similar cases.

Conclusion: Anatomical and clinical context should guide surgical strategy in gallstone ileus. Distal enterotomy with enterolithotomy can be safe and effective in selected cases, with delayed biliary surgery reserved for symptomatic recurrence. Further research is needed to clarify the optimal timing and approach.

Keywords: Case report; Enterolithotomy; Enterotomy; Gallstone ileus; Intestinal obstruction; Laparotomy.

Fig. 1

Erect abdominal x-ray showing multiple Air-Fluid levels.

Fig. 2

Axial CT abdomen with contrast showing a large stone impacted in the distal ileum with proximal small bowel dilatation and distal collapse.

Fig. 3

Axial contrast-enhanced CT image demonstrating a cholecysto-duodenal fistula. The image shows direct communication between the gallbladder and the adjacent duodenum (arrow), evidenced by pneumobilia and an indistinct gallbladder wall.

Fig. 4

Large Gallbladder stone impacted in the distal ileum.

Fig. 5

Stone after extraction.