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.

• 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]

  Table 1: Differential diagnosis of common urgent and emergent causes of abdominal pain in the elderly Click here to view Of patients presenting to the ED with abdominal pain, approximately 2% have an obstruction, with the probability of obstruction increasing [ijam-web.org]

• 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]

• 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]

• 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]

  Abdominal distension develops. Initially the patient may pass stools or flatus but not later. Vomiting occurs some hours after the onset of pain and it may be faeculent. Signs Patients with gallstones are often, but not invariably, obese. [patient.info]

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

• Colic

  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]

  Code K56.0 Paralytic ileus 2016 2017 2018 2019 Billable/Specific Code Applicable To Paralysis of bowel Paralysis of colon Paralysis of intestine Type 1 Excludes gallstone ileus ( K56.3 ) ileus NOS ( K56.7 ) obstructive ileus NOS ( K56.69- ) Gallstone (colic [icd10data.com]

  They underline the risk of performing an anastomosis in these areas, since the inflammatory substrate could negatively impact on the sutures, mainly at colic level. [omicsonline.org]

  Approximately two months previously, she had presented with symptoms of biliary colic, which was subsequently regressed with non-steroidal anti-inflammatory drugs. [jmedicalcasereports.biomedcentral.com]

• Biliary Colic

  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]

  Approximately two months previously, she had presented with symptoms of biliary colic, which was subsequently regressed with non-steroidal anti-inflammatory drugs. [jmedicalcasereports.biomedcentral.com]

  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]

• Distractibility

  Despite gallstone is uncommon cause of intestinal obstruction, a high index of suspicion with a careful CT scan interpretation is the key to the diagnosis, especially when there is a red-herring distracting the attention, like irreducible hernia in this [ncbi.nlm.nih.gov]

• 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.

• Gastric Fistula

  In the case of fistula without the complication of gallstone ileus, the treatment approach has been cholecysto-gastric fistula closure with a gastroplastic using separate stitches and cholecystectomy, in one-stage. [ncbi.nlm.nih.gov]

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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.