Gallstone ileus is one of the variants of mechanical intestinal obstruction caused by blockage of the intestine by a gallstone. Pathology occurs during the formation of a biliodigestive fistula, through which large concretions enter the gastrointestinal tract. Symptoms of the disease include spastic pains throughout the abdomen, acute retention of stool and gases, increasing intoxication syndrome. To make a diagnosis, the results of ultrasound, survey radiography and computed tomography of the abdominal organs are necessary. Surgical treatment: emergency surgery to decompress the intestine and extract the concretion, followed by a planned cholecystectomy.
K56.3 Gallstone ileus
Gallstone ileus is a rare complication of cholelithiasis (GI), which occurs in 0.1–0.6% of patients with long-term experience of this disease. The peak of pathology diagnosis occurs after the age of 60 years, and among patients older than 70 years, the risk of complications increases to 24%. Women get sick 3-5 times more often than men, which is due to their greater predisposition to the development of GI. If the biliary concretion is located in the duodenum 12, such a subspecies of ileus is called Bouveret syndrome in honor of the French clinician who first described the disease in 1896.
Causes of gallstone ileus
The cause of intestinal obstruction in gallstone ileus is blockage of the lumen by a gallstone. Pathology occurs with a large concretion — more than 2.5 cm in diameter. Stones of this size are not able to enter the gastrointestinal tract through the biliary duct. I associate their penetration with the presence of biliodigestive fistulas – pathological connections between the gallbladder and any part of the intestine.
Fistulous passages are formed during recurrent attacks of cholecystitis, which are accompanied by a adhesive process and dense fusion of the gallbladder with the intestinal wall. Up to 68% of cases are cholecystoduodenal fistulas — connections of the biliary system with the duodenum 12. Less common are cholecystotonic intestinal and cholecystopodic fistula passages. Through them, large gallstones penetrate into the gastrointestinal tract and cause gallstone ileus.
In rare cases, gallstone intestinal obstruction is observed when small concretions are ingested. In such a situation, it is caused by a pathological intestinal spasm that occurs in response to irritation of its wall from the inside. Some authors suggest that spasm in contact with small gallstones develops due to the primary increased irritability of the gastrointestinal tract due to the peculiarities of visceral nervous regulation.
In most patients, stones are located in the jejunum at a distance of 70-100 cm from the Treitz ligament. Less often, the stones are localized in the terminal part of the ileum, since it has the smallest diameter. Another typical location is called the duodenum, which is observed in Bouveret syndrome. The rate of development of symptoms depends on the level of occurrence of the stone. The pathophysiological mechanisms are identical to other forms of intestinal obstruction.
One of the key factors of pathogenesis is called microcirculatory disorders, which are caused by a reduction in arterial inflow and difficulty in venous outflow of blood. The disease is also accompanied by violations of the water-electrolyte balance associated with the loss of water and chlorine ions with vomit, swelling of the intestinal wall and mesentery, accumulation of chyme and feces in the proximal gastrointestinal tract.
Gallstone ileus symptoms
The development of the clinical picture of intestinal obstruction is preceded by an attack of exacerbation of cholecystitis, which took place 24-48 hours ago. Patients complain of habitual pains in the right hypochondrium, which gradually spread throughout the abdomen. The pain increases and becomes cramping. Against the background of the pain syndrome, the discharge of gases and stool stops, after which vomiting occurs. With a high level of intestinal blockage, vomiting is repeated, with a low one – time.
The patient has a swollen and asymmetrical abdomen, the muscles of the anterior abdominal wall are moderately tense. In people of a thin build, with careful palpation of the abdomen, it is possible to determine the zone of maximum soreness and to palpate a dense formation — a bile concretion. With the development of the classic symptoms of intestinal obstruction, the pain becomes paroxysmal, becomes excruciating and unbearable.
Local symptoms are accompanied by signs of general intoxication of the body. The skin becomes painfully pale and covered with cold sweat, appetite is completely absent. Characterized by a weak and frequent pulse, low blood pressure. Occasionally there is an increase in temperature to subfebrile figures. A pattern is characteristic of the gallstone ileus: the higher the stone is located in the intestinal lumen, the more violent and severe the onset of the disease.
Gallstone ileus is characterized by a severe course, which is due to the senile age of patients, their late admission to the hospital and the presence of multiple concomitant pathology. One of the most dangerous consequences is considered to be necrosis of the intestinal wall and its perforation, provoking fecal peritonitis. Intestinal obstruction causes dehydration, hypovolemic and toxic shock. Septic complications and multiple organ failure are not excluded.
Diagnostics of gallstone ileus
Examination of patients with signs of ileus is carried out by a surgeon in a hospital. Valuable information is obtained when clarifying the anamnesis: the long-term existence of GI is characteristic, frequent exacerbations of cholecystitis and repeated visits to specialists. During physical examination, attention is paid to abdominal pain during palpation, increased peristalsis and intestinal noises during pain attacks. To confirm the diagnosis, the following studies are prescribed:
- Abdominal x-ray. If gallstone ileus is suspected, an overview radiography is performed, with the help of which the Cloiber bowls are determined. In 50% of patients, the Rigler triad is observed: pneumobilia, opacity in the right iliac region, expansion of the loops of the small intestine with simultaneous lack of air in the colon.
- Abdominal ultrasound. Ultrasound diagnostics is used as a screening method to determine gallstone and pathology of the biliary tract. This suggests a diagnosis of chronic calculous cholecystitis complicated by gallstone obstruction.
- CT of the abdominal cavity. The study is called the “gold standard” for the diagnosis of gallstone ileus. CT is used to clearly visualize the gallstone, determine the location and length of the gallbladder fistula. The specificity of the technique reaches 100%, the sensitivity is more than 93%.
- Blood test. There are no specific laboratory signs of the disease, but the results of the studies are important for assessing the general condition of the patient. In the hemogram, leukocytosis is determined, an increase in hematocrit, which indicates dehydration. In the biochemical analysis, hypokalemia and hypochloremia are observed, the level of hepatic and pancreatic enzymes remains within the normal range.
When making a diagnosis, other mechanical causes of intestinal obstruction are excluded: compression of the intestine by a benign or malignant tumor, adhesive disease, strangulated hernia. Fecal stones, massive worm infestation and foreign bodies should be excluded, which also cause blockage of the intestinal lumen. In elderly patients, gallstone ileus is necessarily differentiated with peritonitis, which may have erased symptoms.
Gallstone ileus treatment
The method of choice is open surgery – enterotomy below the obturation site. With timely detection of pathology and the absence of irreversible changes in the intestinal wall, the incision is sutured without the imposition of a joint, which shows good long-term results and contributes to the early normalization of intestinal peristalsis. With a strong fixation of the gallstone and signs of destruction of the intestinal wall, intestinal resection with the imposition of an anastomosis is indicated.
At the first stage of the operation, the closure of the biliodigestive fistula is not performed, which is due to the general serious condition of the patient. The second stage of treatment is radical cholecystectomy to disconnect the intestine from the biliary tract, performed as planned. It is recommended to carry out it to all patients, since cases of recurrence of intestinal obstruction with repeated ingestion of concretions into the gastrointestinal tract are not excluded.
Drug therapy is carried out in the pre- and postoperative period. It includes non-specific measures aimed at stabilizing the patient’s condition. A nasogastric probe is installed to decompress the stomach. With the help of water-salt solutions, the correction of electrolyte and acid-base equilibrium is carried out. Antibacterial therapy is used to prevent purulent-septic complications.
Prognosis and prevention
Despite the success of abdominal surgery, mortality in gallstone ileus reaches 20%. Patients over 70 years of age, people with severe somatic pathologies are at high risk. If the biliodigestive fistula was not closed during repeated surgery, the probability of recurrence is up to 50%. Prevention consists in timely treatment of GI, rational choice of operative tactics for the treatment of cholecystitis, medical examination of patients with biliary pathologies.
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