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]

• 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]

• Acute Abdomen

  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]

  : Biliary ileus; Cholelithiasis; Cholecystoduodenal fistula; Acute abdomen; Computed tomography; Inguinal hernia. · · · ( pdf ) [scielo.conicyt.cl]

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

  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]

  [Gallstone ileus as a cause of acute abdomen. Importance of early diagnosis for surgical treatment.Cir Esp. 2013; 91 (8): 485-9. In article CrossRef PubMed [23] Clavien PA, Richon J, Burgan S, Rohner A. Gallstoneileus.Br J Surg 1990; 77 (7): 737-42. [pubs.sciepub.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]

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]

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]

Prognosis Because the condition tends to affect the old and frail, there is a 20% mortality. There appears to be no real difference in terms of the operative procedure performed - eg, simple enterolithotomy to fistula repair. [ 12 ] [patient.info]

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]

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]

Service de chirurgie B, E3, CHU Hassan II, Fes, CP 30000, Maroc, tel : 0021265600722 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 [scienceopen.com]

Epidemiology of Gallbladder Disease: Cholelithiasis and Cancer. Gut Liver. 2012;6(2):172-87. . 11. Sánchez-García M, Tomoiu IG, Reina-Escobar D, Delgado-Casado JA. Causa infrecuente de obstrucción intestinal. Semergen. 2015;41(4):18-20. . 12. [redalyc.org]

EPIDEMIOLOGY Gallstone ileus has shown a constant incidence of 30-35 cases/1000000 admissions over a 45-year period[ 5 ]. This entity develops in 0.3%-0.5% of patients with cholelithiasis[ 6 ]. [ncbi.nlm.nih.gov]

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

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

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

PATHOPHYSIOLOGY Gallstone ileus is frequently preceded by an initial episode of acute cholecystitis. The inflammation in the gallbladder and surrounding structures leads to adhesion formation. [ncbi.nlm.nih.gov]

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]

[…] obstructions, often requiring operative stone removal. [7] Two surgical approaches commonly used are enterolithotomy alone or enterolithotomy, cholecystectomy, and fistula closure in a single surgical procedure. [5], [7] The latter technique has the benefit of preventing [ijam-web.org]

[…] dehiscence, myocardial infarction, pneumonia are more likely to occur with one stage procedure when compared with simple enterolithotomy (61.1% to 27.3%). [4] However, few authors like Sfairi et al. recommend one stage procedure for gallstone ileus to prevent [ijcasereportsandimages.com]

However, one should remember that laparoscopy is somehow more challenging in those patients because of the dilated and edematous bowel in those cases that require gentle manipulation of the bowel to prevent perforation. [saudijgastro.com]

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.