Diagnosis

Gallstone Ileus

Etiology

Cause/Pathophysiology [dzo]

1. Large gallstone --> cholecystitis --> adhesions to adjacent GI tract (duodenum)

2. Pressure necrosis --> eroding a hole through the gallbladder wall into the small bowel (usually a cholecystoduodenal fistula, 68%)

3. Rarely, a gallstone may pass through a dilated common bile duct and papilla of Vater

4. The site of fistula, the size of gallstone and the bowel lumen size determine the impaction location causing bowel obstruction:

   • Ileocecal valve (73%) [oy5]

   • Pylorus or proximal duodenum (gastric outlet obstruction/Bouveret syndrome) [wgp]

   • Colon sigmoid obstruction (rare)

Risk factors [dzo]

• Women

• Age > 60

• Long history of cholelithiasis

• Repeated episodes of acute cholecystitis

• Gallstones > 2 cm

Complications [dzo]

• Bowel obstruction

• Infection

• Pancreatitis

• Complications to treatment

  • Acute renal failure, wound dehiscence, biliary fistula, sepsis, urinary tract infections, anastomotic leaks, intra-abdominal abscess, and death

Epidemiology

Incidence per 100.000 [du4][t74][oy5]

Approach

• Abdominal x-ray

• CT abdomen

• Ultrasound abdomen

• MRCP

• ERCP

Diagnostic criteria

1. Cholelithiasis

2. Biliary-enteric fistula (or ERCP/papillotomy)

3. Intestinal obstruction

Treatment

1. Endoscopy: [evp]

   • ERCP

   • Lithotripsy (endoscopic or extracorporeal)

2. Surgery: [evp]

   • Enterotomy

   • Cholecystectomy (performed during the primary operation or later)

   • Fistula closure

Differential diagnoses

Abdominal abscess, Acute pancreatitis, Adhesion, Appendicitis, Benign bile duct tumor, Benign neoplasm of the small intestine, Celiac disease, Cholangiocarcinoma, Cholecystitis, Choledocholithiasis, Cholelithiasis, Colorectal cancer, Crohn disease, Diverticulitis, Femoral hernia, Foreign body, Gastrointestinal obstruction, Hypokalemia, Incisional hernia, Infectious colitis, Inguinal hernia, Intussusception, Ischemic colitis, Lymphoma, Meckels diverticulum, Ovarian torsion, Perforated ulcer, Peutz-Jeghers syndrome, Postoperative paralytic ileus, Radiation enteritis, Ruptured ectopic pregnancy, Small bowel cancer, Umbillical hernia, Volvulus