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Gallstone Ileus, Emergency Medicine

Basics

Description

- Site of impaction - Terminal ileum most common (54-65%) - Narrowest part of small intestine at level of ileocecal valve

  • Mechanical intestinal obstruction secondary to impaction of a gallstone within bowel lumen
  • Stone is usually >2.5 cm
  • 1-3% of all intestinal obstructions
  • Most cases occur in patients >65
  • Female > male (5:1)
  • Mortality 15-18%

Etiology

  • Chronic gallbladder inflammation causes adhesions between gallbladder and adjacent bowel wall
  • Cholecystocolonic fistula develops, permitting stone passage into intestine:Duodenum is the most common site of fistula formation, followed by colonGastric fistulas are possible but rare
  • Site of impactionTerminal ileum most common (54-65%)Narrowest part of small intestine at level of ileocecal valveJejunum (27%)Duodenum (1-3%)Gastric outlet obstruction caused by duodenal impaction referred to as Bouveret syndromeLarge bowel obstruction is rare

Diagnosis

Signs and Symptoms

  • "Tumbling" abdominal discomfort:Episodic abdominal pain as stone lodges and dislodges throughout the intestines.Complete impaction leads to severe, often acute abdominal pain.
  • Nausea
  • Vomiting:Can be bilious or feculent
  • Obstipation
  • Abdominal distention and tympany
  • Abdominal tenderness:Peritoneal findings develop late in the course of disease
  • Abnormal bowel sounds

History

  • Only 50-60% of patients have a history of biliary colic or gallstone disease.
  • Gallstone ileus has been associated with cardiovascular disease, diabetes, and obesity.

Physical Exam

  • Abdominal exam for:Abdominal distension/tenderness
  • Jaundice may occur

Essential Workup

Evaluate for intestinal obstruction.

Diagnosis Tests & Interpretation

Lab

  • Electrolytes, BUN/creatinine, glucose since decreased oral intake and vomiting leads to electrolyte abnormality
  • Liver function panel and bilirubin may be elevated
  • Amylase:Elevated in late obstructions
  • CBC/hematocrit:Hemoconcentration secondary to dehydration
  • Elevated WBC nonspecific

Imaging

  • Flat and upright abdominal radiographs:Multiple air-fluid levels and distended bowel consistent with bowel obstructionRigler triad: 2 of 3 pathognomonic (present in 30-50%):Air in the biliary tree (pneumobilia)Partial or complete bowel obstructionEctopic stone visualized within the intestinal tract
  • CXR:Evaluate for pneumoperitoneum
  • Abdominal CT scan:Test of choiceCan directly visualize and localize stone within intestinal lumen
  • Abdominal US:Can identify pneumobilia and gallstones, but lower yield in locating obstructing stone

Differential Diagnosis

  • Paralytic ileus
  • Extrinsic bowel obstruction:AdhesionsVolvulusHerniaIntussusception
  • GI malignancy
  • Diverticulitis
  • Bezoar
  • Inflammatory bowel disease
  • Pseudo-obstruction
  • Cholecystitis
  • Ascending cholangitis
  • Pancreatitis

Treatment

Pre-Hospital

Establish IV access

Initial Stabilization/Therapy

IV fluid resuscitation

Ed Treatment/Procedures

  • Nasogastric suction to decompress the stomach and intestine
  • Nothing PO
  • Electrolyte replacement
  • Monitor urine output
  • Analgesics
  • Broad-spectrum antibiotics to cover bowel flora:Piperacillin/tazobactamAmpicillin/sulbactamTicarcillin/clavulanateAlternatives include imipenem, meropenem, 3rd-generation cephalosporin + metronidazole.
  • Surgical consultation

Medication

  • Ampicillin/sulbactam: 3 g IV q6h (peds: 100-200 mg/kg/24 h)
  • Piperacillin/tazobactam: 3.375 g IV q6h (peds: 240-400 mg/kg/24 h)
  • Ticarcillin/clavulanate: 3.1 g IV q4-6h

Follow-Up

Disposition

Admission Criteria

  • Admit all patients with gallstone ileus
  • Surgical evaluation for emergent operative intervention

Discharge Criteria

None

Followup Recommendations

Surgical consultation in ED for evaluation and operative intervention

Pearls and Pitfalls

  • Gallstone ileus is a mechanical intestinal obstruction rather than a true ileus.
  • Emergent surgical consultation is required for definitive management.
  • High mortality rates stem from delay in diagnosis and patient comorbidities.
  • Suspect gallstone ileus in elderly patients, especially women, with signs/symptoms of bowel obstruction and no previous surgical history.
  • Only 10% of ectopic gallstones can be visualized on plain radiographs. CT imaging is more sensitive and specific for detecting intraluminal stones.
  • Only 1/2 of the patients have a previous history of biliary colic or gallstone disease.

Additional Reading

  • Bennett GL, Balthazar EJ. Ultrasound and CT evaluation of emergent gallbladder pathology. Radiol Clin North Am. 2003;41:1203-1216.
  • Chou JW, Hsu CH, Liao KF, et al. Gallstone ileus: Report of two cases and review of the literature. World J Gastroenterol. 2007;13:1295-1298.
  • Lobo DN, Jobling JC, Balfour TW. Gallstone ileus: Diagnostic pitfalls and therapeutic successes. J Clin Gastroenterol. 2000;30(1):72-76.
  • Rosenberg M, Parsiak K. Vomiting gravel. Am J Emerg Med. 2004;22(2):131-132.
  • Zaliekas J, Munson JL. Complications of gallstones: The Mirizzi syndrome, gallstone ileus, gallstone pancreatitis, complications of "lost" gallstones. Surg Clin North Am. 2008;88:1345-1368.

See Also (Topic, Algorithm, Electronic Media Element)

  • Cholecystitis
  • Cholelithiasis

Codes

ICD9

560.31 Gallstone ileus

ICD10

K56.3 Gallstone ileus

SNOMED

  • 37976006 gallstone ileus (disorder)