Gallstone ileus: Report of two cases and review of the literature

Abstract

Gallstone ileus is a rare disease and accounts for 1%-4% of all cases of mechanical intestinal obstruction. It usually occurs in the elderly with a female predominance and may result in a high mortality rate. Its diagnosis is difficult and early diagnosis could reduce the mortality. Surgery remains the mainstay of treatment. We report two cases of gallstone ileus. The first was a 78-year old woman who had a 2-d history of vomiting and epigastralgia. Plain abdominal film suggested small bowel obstruction clinically attributed to adhesions. Later on, gallstone ileus was diagnosed by abdominal computed tomography (CT) based on the presence of pneumobilia, bowel obstruction, and an ectopic stone within the jejunum. She underwent emergent laparotomy with a one-stage procedure of enterolithotomy, cholecystectomy and fistula repair. The second case was a 76-year old man with a 1-wk history of epigastralgia. Plain abdominal film showed two round calcified stones in the right upper quadrant. Fistulography confirmed the presence of a cholecystoduodenal fistula and gallstone ileus was also diagnosed by abdominal CT. We attempted to remove the stones endoscopically, but failed leading to an emergent laparotomy and the same one-stage procedure as for the first case. The postoperative courses of the two cases were uneventful. Inspired by these 2 cases we reviewed the literature on the cause, diagnosis and treatment of gallstone ileus.

Multidetector computed tomography diagnosis of ileal and antropyloric gallstone ileus

“…[1,2] Antropyloric gallstones, a variant of Bouveret syndrome, are a very rare cause of gastric outlet obstruction. [6] The mortality rate is between 12 and 27%, due to concomitant diseases and the delayed diagnosis.…”

“…[7] The presenting clinical situation is variable and nonspecific, but often includes nausea, vomiting and epigastric pain. [2,3,7] The classic radiographic triad of small bowel obstruction, pneumobilia and an ectopic gallstone, as described by Rigler (1941), [7,8] is specific for gallstone ileus. Unfortunately, this triad of findings is suggested in only 30-35% of abdominal plain radiographs in the reported cases.…”

Management Options of Bouveret's Syndrome

“…In fitter and younger patients or those with persistent biliary tract symptoms, a cholecystectomy is necessary [16]. These pathological "non-surgical" fistulae are potentially harmful as they tend to open and close leading to recurrent cholecystitis and cholangitis when drainage is inadequate.…”

Gallstone Ileus: Diagnostic and Surgical Dilemma

“…GSI accounts for 1-3% of all mechanical intestinal obstruction and occurs mainly in elderly patients and it is becoming more common as a result of increase the aging population [1]. There is a female predominance (female to male ratio is 3.5-6:1).…”