J K Selwyn, M D Witham, K Flatman, S Meldrum, M E T Mcmurdo
Ageing and Health, Division of Medicine and Therapeutics, Ninewells Hospital and Medical School, University of Dundee, Dundee DD1 9ES
Correspondence to J K Selwyn, Specialist Registrar to Prof M E T Mcmurdo, Ageing and Health Ninewells Hospital, Dundee DD1 9ES
E mail: jey.selwyn@tpct.scot.nhs.uk
SMJ 2007 52(2): 56
Gallstone ileus is an uncommon and peculiar complication of cholelithiasis in an older population. Perioperative mortality rates are high as this condition is difficult to diagnose, often lead to delay in treatment and high percentage older patients have multiple co-morbidities. Atypical presentations are common in older patients, most of who present to medical rather than surgical units, further delaying definitive treatment. We discuss a 79 year old female patient who presented with severe dehydration due to gastrointestinal symptom with no typical clinical signs of intestinal obstruction.
Keywords: Gallstone ileus, obstruction, laparotomy, enterolithotomy.
A 79 year old female presented to the medical unit with a five day history of nausea, vomiting. These symptoms were preceded by mild abdominal pain. She was a lifelong smoker and received treatment for hypertension and chronic obstructive airway disease. Physical examination revealed no fever and vital signs were stable. Systems examinations revealed normal heart sound and quite breathe sound on auscultation and soft abdomen with no distension. Her weight was found to be low and the BMI was 17. Laboratory investigation revealed urea 48mmol/l, creatinine 187mmol/l with normal liver function tests and full blood count. After successful fluid replacement, renal function reverted to normal and the patient settled initially with intravenous fluid and antiemetic. A few days later the patient had further vomiting, again with no clinical signs of intestinal obstruction, but her abdominal film showed small bowel obstruction (Fig1). She underwent a diagnostic laparotomy which showed impaction of a gallstone (Fig2) in the terminal ileum which was then removed by enterolithotomy.
Gallstone ileus was first described by Bartholin in 1654 as a complete or incomplete mechanical intraluminal obstruction caused by impaction of gallstone(s), which have migrated from the gallbladder to the intestinal tract following fistulization between gall bladder and the duodenum. It is a geriatric surgical emergency accounting for 25% of mechanical intestinal obstruction1. This condition occurs more commonly in women than men with a ratio of 16:1 in one study 2. It is observed in patients with recurrent episode of cholecystitis and usually seen in obese persons. Unlike our patient who had no history of cholecystitis and she was with low weight. It causes symptoms and signs of small bowel obstruction if the gallstone impacts at the ileocaecal junction. As in our patient, intermittent recurrence of symptoms over several days is an important clinical presentation. The diagnosis is often delayed due to non-specific findings on clinical examination. Invariably such patients are admitted to medical assessment unit due to their atypical presentation. It has a high morbidity (18%) and mortality (17%) if left untreated. The preferential sites for impaction by the gallstone(s) are the ligament of Treitz, the terminal ileum or any stricture of small bowel. A rare form of gallstone ileus is a gastric outlet obstruction, also known as Bouveret’s syndrome.
The plain abdominal X-ray may reveal the signs of small bowel obstruction, pneumobilia and ectopic gallstone 3 (Rigler’s triad). The presence of two of these signs are considered pathognomonic, but is seen in only 30 -35% of cases. In our patient there was no pnemobilia on the abdominal X-ray and no history of cholecystitis. The stone(s) may be located in the pelvic loops and project on the sacrum or bony pelvis. They are not always detected as they are frequently made of cholesterol with only a thin layer of calcification 4. The other causes of a radio- opaque shadow in the right iliac fossa include appendicolith, bladder stone, and ureteral stone. Computed tomography is increasingly used for early diagnosis 5 in small bowel obstruction and it is more sensitive in detecting gallstone ileus as it shows the cholecystoduodenal fistula and intraluminal gall stone even if the stone is not heavily calcified. Relief of obstruction remains the main stay of treatment. Enterolithotomy is the better surgical option as it is safe in high-risk patients.
Learning points
Gallstone ileus is a common surgical emergency in older females. Presentation to a medical unit, rather than a surgical unit is common.
Delay in confirming the diagnosis is not uncommon and if left untreated the mortality is high
A high index of suspicion in older patients with intermittent gastro-intestinal symptoms and a history of cholecystitis should trigger appropriate sensitive investigation like Computerised Tomography of the abdomen or diagnostic laparotomy.
References
Clavien PA, Richon J, Burgan S, Rohner A. Gall stone ileus. Br J Surg 1990; 77: 737 - 742 3.
Rigler LG, Borman CN, Noble JF. Gallstone obstruction. JAMA 1941; 117: 1753 - 9 4.
Swift SE, Spencer JA. Gallstone ileus: CT findings. Clin Radiol 1999: 54: 451 - 454 5. Maglinte DDT, Balthazarej, Kelvin FM, Megibow AJ.
The role of radiology in the diagnosis of small bowel obstruction. Am J Roentgenol 1997; 168: 1171 - 1180