Basics
Description
- 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 colon
- Gastric fistulas are possible but rare
- Site of impaction
- Terminal ileum most common (54-65%)
- Narrowest part of small intestine at level of ileocecal valve
- Jejunum (27%)
- Duodenum (1-3%)
- Gastric outlet obstruction caused by duodenal impaction referred to as Bouveret syndrome
- Large 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 obstruction
- Rigler triad: 2 of 3 pathognomonic (present in 30-50%):
- Air in the biliary tree (pneumobilia)
- Partial or complete bowel obstruction
- Ectopic stone visualized within the intestinal tract
- CXR:
- Evaluate for pneumoperitoneum
- Abdominal CT scan:
- Test of choice
- Can 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:
- Adhesions
- Volvulus
- Hernia
- Intussusception
- 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/tazobactam
- Ampicillin/sulbactam
- Ticarcillin/clavulanate
- Alternatives 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)