Gallstone ileus. A continuing surgical problem

CT Diagnosis of Gall Stone Ileus

We report a case of gall stone ileus in which only small bowel obstruction was seen on the conventional abdominal film and the diagnosis was made by computed tomography (CT). With the availability of CT and its increasing use in the investigation of the acute abdomen, CT examination will occasionally be performed on gall stone ileus patients. Awareness of the CT findings in gall stone ileus will result in early diagnosis leading to a reduction in the mortality rate.

Value of CT in the diagnosis and management of gallstone ileus

AIM: To retrospectively establish the diagnostic criteria of gallstone ileus on CT, and to prospectively apply these criteria to determine the diagnostic accuracy of CT to confirm or exclude gallstone ileus in patients who presented with acute small bowel obstruction (SBO). Another purpose was to ascertain whether the size of ectopic gallstones would affect treatment strategy.

METHODS: Fourteen CT scans in cases of proved gallstone ileus were evaluated retrospectively by two radiologists for the presence or absence of previously reported CT findings to establish the diagnostic criteria. These criteria were applied in a prospective contrast enhanced CT study of 165 patients with acute SBO, which included those 14 cases of gallstone ileus. The hard copy images of 165 CT studies were reviewed by a different group of two radiologists but without previous knowledge of the patient’s final diagnosis. All CT data were further analyzed to determine the diagnostic accuracy of gallstone ileus when using CT in prospective evaluation of acute SBO. The size of ectopic gallstone on CT was correlated with the clinical course.

RESULTS: The diagnostic criteria of gallstone ileus on CT were established retrospectively, which included: (1) SBO; (2) ectopic gallstone; either rim-calcified or total-calcified; (3) abnormal gall bladder with complete air collection, presence of air-fluid level, or fluid accumulation with irregular wall. Prospectively, CT confirmed the diagnosis in 13 cases of gallstone ileus with these three criteria. Only one false negative case could be identified. The remaining 151 patients are true negative cases and no false positive case could be disclosed. The overall sensitivity, specificity and accuracy of CT in diagnosing gallstone ileus were 93%, 100%; and 99%, respectively. Surgical exploration was performed in 13 patients of gallstone ileus with ectopic stones sized larger than 3 cm. One patient recovered uneventfully following conservative treatment with an ectopic stone sized 2 cm in the long axis.

CONCLUSION: Contrast enhanced CT imaging offered crucial evidence not only for the diagnosis of gallstone ileus but also for decision making in management strategy.

Case report: ultrasound in the diagnosis of gallstone ileus

Recent case reports have shown that ultrasound can be useful in the diagnosis of gallstone ileus. A further patient is presented in whom the ultrasonic demonstration of dilated bowel loops, air in the gall-bladder, and an ectopic gallstone clinched the diagnosis when the plain radiographs demonstrated only small bowel obstruction. A pitfall in the ultrasound diagnosis is also discussed.

The cholecystogastric fistula

Internal gall bladder fistulas with a hollow viscus following dislocation of a gallstone into the intestine represent one of the late sequelae of cholelithiasis. We report the case of a 78-year-old patient, who suffered from a cholecystogastric fistula with consecutive stone transmigration into the stomach.

[Gallstone ileus--a diagnostic and indications problem--report on 35 patients]

The clinical data of 35 patients with gallstone ileus treated between 1970 and 1984 at the Department of Surgery of the University Hospital of Freiburg were retrospectively analysed with respect to duration of symptoms prior to surgery, preoperative diagnostic, operative procedure and outcome. No reliable test could be found that will lead the clinician to the correct diagnosis in most cases. The classical sign of gallstone ileus--small bowel obstruction combined with pneumobilia in the plain abdominal X-ray--was apparent only in 20%. So, a high index of suspicion, especially in old female patients with small bowel obstruction and prompt surgical intervention will decrease mortality. Enterotomy with removal of the stone without simultaneous cholecystectomy can be recommended as a safe procedure even in very old patients.

Improving the outcome in gallstone ileus

A 32 year retrospective review of 24 cases of gallstone ileus from the hospitals of Oregon Health Sciences University has been presented. Nineteen patients (79 percent) were female and 18 (75 percent) were more than 70 years of age. Fifty-four percent of the patients had a correct preoperative diagnosis that correlated well with the roentgenographic findings. Enterolithotomy was the most frequently employed operation, and cholecystoduodenal fistulas were positively identified in 61 percent of the patients. Most obstructions occurred in the distal ileum (48 percent). Wound infections occurred in six patients (26 percent), and there were three deaths for a mortality rate of 13 percent. Of note, the incidence of wound infections and mortality is found to be decreasing. This is related to the more frequent use of prophylactic antibiotics. The controversy regarding performing an enterolithotomy alone versus a one stage procedure has been reviewed and several interesting and atypical cases have been briefly discussed.

Small bowel ulceration and perforation by a gallstone

Gallstone ileus is a well recognised entity and is responsible for approximately 3 per cent of intestinal obstructions. It is, however, quite rare for a gallstone to cause numerous ulcerations of the bowel mucosa and perforation especially in the absence of prior clinical or radiological signs of obstruction (1). We report a case of ulceration and perforation of the ileum by a gallstone and presenting as acute peritonitis rather than obstruction.

Gallstone obstruction of the colon. Report of two cases and review of management

Gallstone ileus is a distinctly unusual cause of colonic obstruction. Two patients, with associated biliary-colonic fistulas, are described. The clinical features and approximate management of this entity are discussed.

Gallstone ileus: a diagnostic problem

A retrospective review of 24 patients with gallstone ileus from our institutions during the period from 1947 through 1981 has been presented. The study was undertaken in an attempt to refine the diagnosis and treatment of this rare entity. The patients ranged in age from 58 to 84 years, and 19 patients were women. The correct preoperative diagnosis was made in 74 percent of the patients using various combinations of clinical history, plain film roentgenograms, and barium contrast upper gastrointestinal series. After an average preoperative hospital stay of 4.5 days, 23 patients required operation. Wound infection developed in nine patients and resulted in wound dehiscence in two. There were four deaths in the patients over 73 years of age (p less than 0.01). Age was the only factor found to correlate with mortality.

Gallstone ileus

Gallstone ileus, although uncommon, requires urgent and appropriate surgical therapy if unacceptable morbidity and mortality are to be avoided. Enterolithotomy alone remains the mainstay of operative treatment for gallstone ileus, but the additional performance of a one-stage cholecystectomy and repair of fistula if desirable if the condition of the patient will allow it. One must use good judgment in selecting a surgical procedure. It is imperative to recall that the primary goal in the surgical treatment of gallstone ileus is to save a life. Future complications of the diseased gallbladder and the cholecystoenteric fistula may be treated electively under more ideal circumstances when and if they occur. Gallstone ileus, like other complications of cholelithiasis, remains a strong argument for early cholecystectomy in patients with gallstones.