Gallstone ileus is the consequence of a gallstone entering the gastrointestinal tract (GIT). In most cases, the stone passes through a fistula formed between the gallbladder and the duodenum [1]. This often follows signs of biliary problems, for example, cholecystitis, with the inflammation contributing to the formation of the fistula.

The stone may pass through the GIT or may be expelled with vomit; alternatively, it may cause partial or complete obstruction, the terminal ileum being the most usual location of impaction. The presentation is of general small bowel obstruction: nausea, vomiting, abdominal pain, and distention. The signs may disappear and reappear since the stone may “tumble” and change position. As the stone migrates towards a distal location, the vomit changes from a light gastric character to a darker shade.

Patients may be excessively ill, anorexic and dehydrated, with fluid and electrolyte imbalances [2]. Fever may indicate peritonitis if the intestines become perforated.

Gallstone ileus constitutes less than 0.1 percent of cases with mechanical obstruction of the GI tract [3]. However, a quarter of the cases with small bowel obstruction in the older population (above 65) can be attributed to gallstone ileus [4].

A rare form of gallstone ileus, called Bouveret syndrome [5], arises when a gallstone is lodged in the duodenum and causes gastric outlet obstruction. Therefore, pain tends to occur around the epigastrium and right hypochondrium, and the stomach is distended.

The disease occurs mainly in elderly females. The mean age of patients has been reported as 68.6 years for Bouveret syndrome [5], and 77 years for gallstone ileus in general [2]. The nonspecific nature of symptoms makes diagnosis problematic, and the advanced age and debility of the patients makes the management of the condition difficult.

• Wound Infection

  Historically, wound infections and dehiscence have been cited as being the most common complications after surgery in 25% to 50% of GI cases. [file.scirp.org]

  A wound infection developed in 4 patients. None of the patients had a recurrence of gallstone ileus. [ncbi.nlm.nih.gov]

  There were postoperative complications in 9 cases (69.2%); 6 of them were medical (46.2%), primarily 4 cases of cardiac insufficiency and 2 of acute pulmonary edema; 6 were surgical (46.2%), 5 surgical wound infections and one evisceration that did not [revistagastroenterologiamexico.org]

  There were three postoperative complications, including wound dehiscence, wound infection and obstructive jaundice (morbidity, 37.5%); and one death due to myocardial infarction (mortality, 11%). [saudijgastro.com]

• Congestive Heart Failure

  Three months prior to admission, she was treated for congestive heart failure. A compensated renal insufficiency was also diagnosed. [onlinelibrary.wiley.com]

  The patient had a past medical history of atrial fibrillation, coronary artery disease, congestive heart failure, hypertension, and COPD. [karger.com]

  Hypertension, diabetes, congestive heart failure, chronic pulmonary disease and anemia are the most common comorbidities[ 8 ]. These associated conditions need to be considered, as they may affect the results of treatment[ 1 ]. [ncbi.nlm.nih.gov]

• Anemia

  […] biliary fistula 回虫症 ascaris lumbricoides 化学性胆嚢炎 chemical cholecystitis 化膿性胆管炎 pyogenic cholangitis オリエンタル胆管炎、再燃性胆管炎 oriental cholangiohepatitis, recurrent pyogenic cholangitis 化膿性胆嚢炎 purulent cholecystitis, cholecystitis purulenta 鎌状赤血球貧血 sickle cell anemia [jsge.or.jp]

  Past history was significant for diabetes mellitus, hypertension, anemia and appendectomy. There was no history of biliary symptoms. On examination patient appeared dehydrated, however her vitals were stable. [ijcasereportsandimages.com]

  Hypertension, diabetes, congestive heart failure, chronic pulmonary disease and anemia are the most common comorbidities[ 8 ]. These associated conditions need to be considered, as they may affect the results of treatment[ 1 ]. [ncbi.nlm.nih.gov]

• Pneumonia

  […] lower morbidity and mortality rate in simple enterolithotomy group, but Riaz et al. showed no difference between the two groups. [3] [6] Doko et al. showed that postoperative complications like wound infection, wound dehiscence, myocardial infarction, pneumonia [ijcasereportsandimages.com]

  Fourth, postoperative recovery is also hampered; age-related complications such as pneumonia or cardiac failure are more frequent than surgery associated complications. [ncbi.nlm.nih.gov]

• Abdominal Pain

  An 80-year-old woman was admitted because of abdominal pain and vomiting. Six months previously, she had presented with abdominal pain and nausea of sudden onset. A CT scan showed thickening of the gallbladder wall and a gallbladder stone. [ncbi.nlm.nih.gov]

  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. [unboundedmedicine.com]

• Vomiting

  A 71-year-old woman complaining of recurrent vomiting and vague epigastralgia for > 2 weeks presented to our department. [ncbi.nlm.nih.gov]

  The stone may pass through the GIT or may be expelled with vomit; alternatively, it may cause partial or complete obstruction, the terminal ileum being the most usual location of impaction. [symptoma.com]

  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. [unboundedmedicine.com]

  On examination, the patient was in moderate distress, vomiting with abdominal tenderness upper quadrants. [epmonthly.com]

• Nausea

  We describe the case of a 94-year-old woman who presented with nausea, vomiting, mild abdominal tenderness, leukocytosis, and a 2.5-cm obstruction in her small bowel. [ncbi.nlm.nih.gov]

  No Comments A 40-year-old Hispanic female presented to our Emergency Department complaining of upper abdominal pain, nausea and vomiting for 1 day. She denies fever; last bowel movement was the previous day. [epmonthly.com]

• Abdominal Distension

  An 89-year-old woman presented with an 8-day history of increasing abdominal distension, pain and associated nausea. Abdominal X-ray demonstrated large bowel dilation. [ncbi.nlm.nih.gov]

  Gallstone ileus can acutely present as colicky abdominal pain and abdominal distension in the course of small bowel obstruction. [radiopaedia.org]

  Abdominal pain is colicky in nature, with freedom from pain between spasms. It is periumbilical and is not clearly localised. Abdominal distension develops. Initially the patient may pass stools or flatus but not later. [patient.info]

• Acute Abdomen

  LEFT: Plain abdominal film in a patient with an acute abdomen, showing no abnormalities. [radiologyassistant.nl]

  abdomen; Computed tomography; Inguinal hernia. · · · ( pdf ) [scielo.conicyt.cl]

  Special article DOI: 10.1016/j.cireng.2013.01.008 Gallstone Ileus as a Cause of Acute Abdomen. Importance of Early Diagnosis for Surgical Treatment El íleo biliar como causa de abdomen agudo. [elsevier.es]

  Case Report An 84 years old female patient was admitted through accident and emergency with a clinical diagnosis of acute abdomen and sepsis. [jpma.org.pk]

  Diagnóstico y Razonamiento The elderly patient with an acute abdomen is not an uncommon presentation in emergency medicine; it is also one of the most concerning, as almost half of such individuals require admission, and between one-fifth to one-third [prognosisapp.com]

• Hypertension

  We report the case of gallstone ileus in an 81-year old woman with typical abdominal pain, arterial hypertension and coronary artery disease. [ncbi.nlm.nih.gov]

  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. [unboundedmedicine.com]

  Past history was significant for diabetes mellitus, hypertension, diverticulitis, total colectomy for lower gastrointestinal bleeding and ventral hernia. [ijcasereportsandimages.com]

  Snapshot An 85-year-old woman with a history of hypertension presents to the emergency department with one-week of nausea, vomiting, and crampy, intermittent right upper quadrant abdominal pain. [medbullets.com]

• Heart Disease

  In our group, the most frequently associated diseases were heart disease and hypertension, which appeared in 40% of patients. [elsevier.es]

  Due to the concurrent diseases (coronary heart disease, congestive heart failure, renal insufficiency) and the weakened state of the patient, an operation was considered unsafe and an endoscopic removal of the stone was tried. [onlinelibrary.wiley.com]

  She had medical history of a huge thyroid nodule (10 x 6 cm), hypertension, atrial fibrillation and ischemic heart disease. On presentation, her vital signs revealed temperature of 36.4 o C, pulse of 97 /min and blood pressure of 160/88 mmHg. [scielo.isciii.es]

  He had past history of ischemic heart disease and was operated for right hydrocele. He was diagnosed with gallstones 2 years back but was not operated by doctors due to poor general and cardiac condition. [casereports.in]

• Vascular Disease

  The condition termed chronic intestinal pseudo-obstruction is also observed in patients with collagen-vascular diseases, visceral myopathy, or neuropathy. [emedicine.medscape.com]

• Biliary Colic

  Symptoms include: pain in your upper abdomen that travels towards your shoulder blade (unlike biliary colic, the pain usually lasts longer than 5 hours) a high temperature (fever) of 38C or above a rapid heartbeat An estimated 1 in 7 people with acute [nhs.uk]

  Only 25% of patients with GSI have history of biliary colic in the preceding one year. [1] The most important investigation in the evaluation of GSI is a scout film of the abdomen. [7] The classic roentgenographic signs, described by Rigler et al, include [jpgmonline.com]

  In our series more than half of the patients had a suspicious history consistent of biliary disorders (simple biliary colic, nausea, vomiting) and previous cholecystitis. [file.scirp.org]

  Discussion Cholelithiasis is a common disease but it is symptomatic in only 20-30% of the cases, most commonly presenting with biliary colic 1. The gallstone ileus is a rare complication of the disease. [causapedia.com]

• Confusion

  Symptoms of acute cholangitis include: pain in your upper abdomen that travels towards your shoulder blade a high temperature jaundice chills confusion itchy skin generally feeling unwell Antibiotics will help treat the infection, but it's also important [nhs.uk]

  One of them is the duodenal ulcer perforated to the biliar ducts, that should not be confused with the cholecyst-enteric fistules, consequence of repeated vesicle inflamatory occurrences. [scielo.br]

• Stroke

  Past history included coronary artery disease, stroke, hypertension, diabetes mellitus, dementia and right hemicolectomy for colon cancer. On examination patients abdomen was mildly tender in the periumblical region. [ijcasereportsandimages.com]

  CASE DESCRIPTION An 80-year old patient, with mild cardiac failure and a history of two previous strokes that had left minimal sequelae, was admitted to another hospital. [scielo.br]

  She had a clinical history of ischemic cerebral stroke 9 years previously, involving left hemiparesis followed by partial functional recovery, hysteroannessiectomy for ovarian cancer 6 years before, followed by pelvic irradiation, gastritis, hypercholesterolemia [omicsonline.org]

The intermittent and nonspecific nature of the symptoms delays the diagnosis. Often days pass after the onset of problems until the patient visits a healthcare facility [6], and the diagnosis may be delayed. The accuracy of diagnosis before surgery is not high (43-73%) [2]. Laboratory studies may show electrolyte and acid-base imbalances.

Plain radiographs have been found useful for diagnosing gallstone ileus. Originally, four characteristic radiological signs that strongly indicate gallstone ileus were described by Rigler et al [7]. Three of the signs are referred to as the Rigler triad: partial or complete intestinal obstruction, pneumobilia, and ectopic gallstone. Observing two of the three in a patient is considered pathognomonic. However, the signs of the Rigler triad are observed variably [1], with less than half of the cases showing signs of the triad [2] [6]. Plain radiographs cannot detect the gallstones themselves because the density of the stones is poor. Gallstones, as well as pneumobilia are recognized by ultrasound [1], but the interpretation of the images may not be unequivocal [5]. Combining results from plain radiography with those from ultrasound improves the diagnosis prior to surgery [8].

Computed tomography (CT) is regarded as the best method for the detection of signs of the Rigler triad [9]. In one study, CT found signs of the Rigler triad in 77% of patients with gallstone ileus, whereas radiography identified the triad in only 14.8% of the cases [10]. CT can diagnose gallstone ileus with a sensitivity of up to 93% [11].

Magnetic resonance cholangiopancreatography is useful for locating gallstones that are not detectable by other methods. Magnetic resonance may be the method of choice for examining patients who are unable to swallow oral contrast material.

• Pneumoperitoneum

  The pneumoperitoneum was established with a Veress needle. A three-port approach (one 5-mm and two 10-mm trocars) and a 30° 10-mm laparoscope were used. [ncbi.nlm.nih.gov]

  In patient number 5, a large pneumoperitoneum was also observed. In the remaining patients, no radiological abnormalities were evident and they were operated on with no clear preoperative cause due to acute abdominal symptoms. [elsevier.es]

  Thus, a plain abdominal film is seldomly useful, with the exception of detection of kidney stones or a pneumoperitoneum. For all other indications use sonography or CT. [radiologyassistant.nl]

  We report a case of an accidental bowel wall injury during diagnostic colonoscopic with consequent pneumoperitoneum; this was followed by expansion of gas through diaphragmatic fenestration perhaps congenital, in right pleural cavity causing pneumothorax [giornalechirurgia.it]

Controversy remains regarding the management of gallstone ileus; surgery is the standard treatment, but also less invasive approaches have proven to be successful. We present an unusual case of gallstone ileus and its conservative treatment. [ncbi.nlm.nih.gov]

Treatment The goal is to Relieve The Obstruction The gold standard procedure is: exploratory laparotomy and enterolithotomy Preoperatively resuscitate the patient and correct metabolic derangements from intestinal obstruction and delayed presentation [authorstream.com]

It is important to look for free fluid, free gas, portal venous gas, or mural gas, as signs of more advanced disease and poorer prognosis. [radiopaedia.org]

Links: aetiology clinical features investigations diagnosis treatment prognosis [gpnotebook.co.uk]

We have concluded, based on the literature that an early diagnosis associated with appropriate therapy can lead to a better prognosis Palabras clave : Ileus; Gallbladder; Intestinal obstruction; Ileus; Vesícula biliar; Obstrucción intestinal. [scielo.org.pe]

Sex, location of the fistula and location of the obstruction did not be related with the prognosis. One-stage procedure is related with higher mortality rate than enterotomy alone. [scienceopen.com]

It constitutes the etiologic factor in less than 5% of cases of intestinal obstruction, but up to one quarter of nonstrangulated small bowel obstructions in elderly patients. [ncbi.nlm.nih.gov]

Med. 2010 February;5(2):E21-E22 Abstract Abstract Gallstone ileus is a rare etiology of small bowel obstruction, occurring typically in the elderly population. The delay in diagnosis often results in significant morbidity and mortality. [journalofhospitalmedicine.com]

Each chapter includes a brief overview of the epidemiology of the clinical problem, the clinical presentation and diagnosis of the problems, and a discussion of the treatment options and potential complications that may arise. [books.google.ro]

Journal Journal ID (nlm-ta): Pan Afr Med J Journal ID (publisher-id): pamj Title: The Pan African Medical Journal Publisher: African Field Epidemiology Network ISSN (Electronic): 1937-8688 Publication date (Electronic): 11 March 2010 Publication date [scienceopen.com]

and colon (5%). [ 1 ] Stones less than 2.5 cm in diameter may traverse the alimentary canal without causing obstruction. [ 2 ] When the gallstone lodges in the duodenum and causes gastric outlet obstruction, it is called Bouveret's syndrome. [ 3 ] Epidemiology [patient.info]

Epidemiology of Gallbladder Disease: Cholelithiasis and Cancer. Gut Liver. 2012;6(2):172-87. http://doi.org/cj3k. 11. Sánchez-García M, Tomoiu IG, Reina-Escobar D, Delgado-Casado JA. Causa infrecuente de obstrucción intestinal. [redalyc.org]

However, to understand and connect the pathophysiology to the imaging features remains the most difficult task radiologists face in their clinical activity. [books.google.it]

Current knowledge of pathophysiology, clinical interventions and methodological challenges was reviewed to inform modern practice and future research. [bjs.co.uk]

Pathophysiology Gallstone ileus occurs when a gallstone passes into the gastrointestinal tract through a bilioenteric fistula. [revistagastroenterologiamexico.org]

PATHOPHYSIOLOGY Biliary-enteric fistulas have many known causes. [scielo.br]

Review of the pathophysiology and management of postoperative ileus. World J Surg. 2006 Aug. 30(8):1382-91. [Medline]. Moore BA, Albers KM, Davis BM, Grandis JR, Toögel S, Bauer AJ. [emedicine.medscape.com]

However, this case supports the need for a systematic search for all enteric stones at laparotomy and consideration of concurrent or interval cholecystectomy and cholecystoenteric fistula repair to prevent recurrent gallstone ileus and determine underlying [ncbi.nlm.nih.gov]

On the contrary, the indications for such intervention are always widening, as its risks become always smaller and the requirements for prevention higher. [books.google.ro]

An early intervention and management is mandatory to prevent mortality10which unfortunately occurred in this case. Conclusion Gallstone ileus and perforation of the small bowel isa rare complication of therapeutic ERCP. [jpma.org.pk]

All RCTs involving an intervention to prevent or reduce POI published between 1990 and 2016 were identified. Grey literature, non‐full‐text manuscripts, and reanalyses of previous RCTs were excluded. [bjs.co.uk]

1. Nuño-Guzmán CM, Marín-Contreras ME, Figueroa-Sánchez M, Corona JL. Gallstone ileus, clinical presentation, diagnostic and treatment approach. World J Gastrointest Surg. 2016 Jan 27;8(1):65-76.
2. Ayantunde AA, Agrawal A. Gallstone ileus: diagnosis and management. World J Surg. 2007 Jun;31(6):1292-1297.
3. Halabi WJ, Kang CY, Ketana N, et al. Surgery for gallstone ileus: a nationwide comparison of trends and outcomes. Ann Surg. 2014 Feb;259(2):329-335.
4. Kirchmayr W, Mühlmann G, Zitt M, Bodner J, Weiss H, Klaus A. Gallstone ileus: rare and still controversial. ANZ J Surg. 2005 Apr;75(4):234-238.
5. Mavroeidis VK, Matthioudakis DI, Economou NK, Karanikas ID. Bouveret syndrome-the rarest variant of gallstone ileus: a case report and literature review. Case Rep Surg. 2013;2013:839370.
6. Abou-Saif A, Al-Kawas FH. Complications of gallstone disease: Mirizzi syndrome, cholecystocholedochal fistula, and gallstone ileus. Am J Gastroenterol. 2002 Feb;97(2):249-254.
7. Rigler LG, Borman CN, Noble JF. Gallstone obstruction: pathogenesis and roentgen manifestations. JAMA 1941;117:1753-1759
8. Ripollés T, Miguel-Dasit A, Errando J, Morote V, Gómez-Abril SA, Richart J. Gallstone ileus: increased diagnostic sensitivity by combining plain film and ultrasound. Abdom Imaging. 2001 Jul-Aug;26(4):401-405.
9. Masannat YA, Caplin S, Brown T. A rare complication of a common disease: Bouveret syndrome, a case report. World J Gastroenterol. 2006 Apr 28;12(16):2620-2621.
10. Lassandro F, Gagliardi N, Scuderi M, Pinto A, Gatta G, Mazzeo R. Gallstone ileus analysis of radiological findings in 27 patients. Eur J Radiol. 2004 Apr;50(1):23-29.
11. Yu CY, Lin CC, Shyu RY, et al. Value of CT in the diagnosis and management of gallstone ileus. World J Gastroenterol. 2005 Apr 14;11(14):2142-2147.