Cramplike Pain and Vomiting in a 77-Year-Old Man

James J. McCombie, MB ChB; Erik D. Schraga, MD

Disclosures

March 28, 2017

Mechanical intestinal obstruction with a gallstone was first described by Bartholin in 1654, with the term "gallstone ileus"; however, this is a misnomer. The symptoms vary depending on the site of impaction and mirror those of intestinal obstruction resulting from any etiology. Classically, the patient presents with subacute episodes of obstruction resulting in abdominal pain and vomiting that subside as the stone spontaneously disimpacts. The symptoms will then recur as the stone becomes larger (because of accrued bowel sediment) and reobstructs the bowel lumen.

On a side note, high duodenal or pyloric impaction produces a clinical picture more akin to gastric outlet obstruction and is known as "Bouveret syndrome." Gallstones account for 1%-4% of all the causes of mechanical intestinal obstruction (up to 25% if considering only patients older than 65 y with nonstrangulated obstruction) and occur more commonly in women.[6] Diagnostic confirmation is notoriously difficult, and as many as 50% of diagnoses are made at laparotomy.[4] Patients often have no previous history of biliary symptoms, and other causes of obstruction are more common, which can lead to clinicians overlooking this condition.

Radiographic clues are responsible for most early diagnoses. On plain abdominal radiography, diagnosis of gallstone ileus is suggested by the Rigler triad (pneumobilia, small-bowel obstruction, and a gallstone in the right iliac fossa). Only 10% of gallstones are visible on radiographs, and gas in the biliary tree and gallbladder has many causes (most commonly iatrogenic).

The Rigler triad can be seen in 15% of patients on abdominal radiography, 11% on ultrasound, and 78% on CT scanning; in fact, CT is often able to identify the fistula itself.[7] Studies support the role of CT scanning in the evaluation of patients with gallstone ileus by highlighting its ability to detect the size, location, and exact number of ectopic stones, and laud its value in the differential diagnosis of acute abdomen.[8]

Upper GI studies, albeit less frequently used, have had some success defining the site of obstruction and demonstrating the fistula via retrograde flow into the biliary tree. CT scanning is also effective, avoiding recurrent obstruction if overlooked.

If a fistula is present (cholecystohepatic, cholecystocholedochal, or bilioenteric), it should be simultaneously repaired and/or controlled during the initial procedure. The case described here was further complicated by an ileal perforation proximal to the site of obstruction. Only a handful of cases of gallstone ileus report such a complication, which normally arises as a result of the pressure of the stone causing necrosis of the bowel wall at the site of obstruction, or increased wall tension caused by distention proximal to the obstruction.[9]

This patient's complication occurred because of a delay in presentation; a delay in the diagnosis also adds to the already significant mortality and morbidity of this condition by allowing the development of further complications (including abdominal sepsis) and decreasing the physiologic reserve of the patient prior to surgery. Patients are typically elderly and are more likely to have comorbidities; these factors explain the overall perioperative mortality of 12%-17%.[6]

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