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| IMAGES IN ACADEMIC MEDICINE |
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| Year : 2016 | Volume
: 2
| Issue : 2 | Page : 253-255 |
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Gallstone ileus: A case of a rolling stone
Allison Zanaboni, Manish Garg
Department of Emergency Medicine, Temple University Hospital, Philadelphia, PA, USA
| Date of Submission | 12-Apr-2016 |
| Date of Acceptance | 11-Jul-2016 |
| Date of Web Publication | 28-Dec-2016 |
Correspondence Address:
Allison Zanaboni
Department of Emergency Medicine, Temple University Hospital, 10th Floor Jones Hall, 1316 W. Ontario Street, Philadelphia, PA 19140
USA
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/2455-5568.196873
Abdominal pain is a common chief complaint and requires a broad differential diagnosis, particularly in the elderly. Certain diagnoses come to mind immediately when evaluating for causes of abdominal pain, but gallstone ileus is not always among those first considered. However, given the high mortality rate it carries, gallstone ileus should be considered in patients with obstructive symptoms, particularly those over the age of 65. The following discussion outlines a case of gallstone ileus and illustrates the classic radiographic finding, known as Rigler's triad, associated with this disease process.
The following core competencies are addressed in this article: Medical knowledge, patient care, practice-based learning and improvement, and systems-based practice.
Keywords: Abdominal pain, bowel obstruction, cholecystitis, cholelithiasis, Rigler's triad
How to cite this article:
Zanaboni A, Garg M. Gallstone ileus: A case of a rolling stone. Int J Acad Med 2016;2:253-5 |
| Introduction | |  |
Cholelithiasis is a common medical condition, affecting about 10–15% of individuals in Western societies, with risk factors of gallstone development being female sex, advancing age, genetic predisposition, obesity, sedentary lifestyle, and hemolytic processes. Fortunately, only a portion of individuals with cholelithiasis develop symptomatic disease. Gallstone ileus is one of the more rare but serious complications of cholelithiasis. Here, we describe a case of gallstone ileus and discuss the classic radiographic findings.
| Case Report | | |
An 85-year-old woman with hypertension and no surgical history presented to the emergency department (ED) with 1 week of worsening, diffuse abdominal pain. Her last bowel movement or passage of flatus was a week prior, and she had begun having nonbloody emesis 4 days before presentation. The patient was afebrile and normotensive; her pulse was 90 beats/min, respiratory rate 24 breaths/min, and oxygen saturation 100%. Physical exam was notable for a distended abdomen with hypoactive bowel sounds and diffuse tenderness without peritoneal signs. Laboratory workup was unremarkable with the exception of a total bilirubin of 1.9 mg/dL and direct bilirubin 0.5 mg/dL. A computed tomography (CT) scan of the abdomen and pelvis with contrast was obtained to evaluate for obstruction or ischemia [Figure 1]. | Figure 1: Coronal image from a computed tomography of the abdomen and pelvis with contrast demonstrating Rigler's triad. (A) Ectopic gallstone within the descending colon, (B) bowel obstruction seen as intestinal dilation proximal to the impacted gallstone, (C) pneumobilia secondary to a cholecystoenteric fistula
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| Discussion | | |
Abdominal pain in the elderly has a broad differential and evaluation is complicated by the lack of classic presentations. When evaluating for common urgent and emergent conditions, it is important to consider anatomical structures complicated by infectious, cardiovascular, or mechanical disease [Table 1]. | Table 1: Differential diagnosis of common urgent and emergent causes of abdominal pain in the elderly
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Of patients presenting to the ED with abdominal pain, approximately 2% have an obstruction, with the probability of obstruction increasing in patients with constipation, prior abdominal surgery or exam demonstrating distension or abnormal bowel sounds.[1]
Various imaging modalities can be used to diagnose abdominal obstruction. The positive likelihood ratio for obstruction on CT is 3.6 versus 1.64 for abdominal X-ray.[1] CT also offers the advantage of differentiating the cause of an obstruction. The most common cause of intestinal obstruction is adhesions from prior surgeries, with other etiologies including hernia, neoplasm, inflammatory bowel disease, volvulus, strictures, intussusception, and as in the case described, gallstones.
Gallstone ileus is a rare but serious complication of cholelithiasis. It is defined as a mechanical intestinal obstruction secondary to an impacted gallstone within the intestinal lumen.[2] Accounting for 1–3% of bowel obstructions, it is more common in the elderly, causing 25% of mechanical obstructions in those over the age of 65,[3],[4] with a female predominance, consistent with the higher prevalence of gallstones in women.[4]
Gallstone ileus results from fistula formation between the biliary tract and intestine, most commonly during acute cholecystitis. An inflamed gallbladder wall becomes adhesed to nearby bowel and allows pressure-induced ischemia from a gallstone to cause erosion and fistula formation, which allows passage of stone into the intestinal lumen.[3] While cholecystoduodenal fistulas occur in 60% of cases, any part of the intestinal tract can be involved.[3],[5]
Most stones smaller than 2–2.5 cm pass through the gastrointestinal (GI) tract unnoticed, but larger stones are prone to become impacted, causing obstruction, most commonly at the narrow terminal ileum.[3]
Symptoms of gallstone ileus are usually insidious, commonly with vague abdominal pain and vomiting, but vary based on the site of obstruction.[2],[4] Patients may have intermittent symptoms as a result of the tumbling phenomenon, seen when a stone is intermittently lodging and passing through the GI tract until a point of impaction.[3],[5]
Diagnosis is based on imaging, with the classing radiographic finding being Rigler's triad. First described in 1941, Rigler's triad consists of ectopic gallstone, intestinal obstruction, and pneumobilia.[3],[6] Originally described for plain film, X-rays are diagnostic in <50% of cases; CT is more sensitive for the diagnosis.[3],[4],[6] All three elements of Rigler's triad are present in only 17–35% of cases of gallstone ileus.[3]
Gallstone ileus is a mechanical obstruction and is treated in a similar manner to other mechanical obstructions, often requiring operative stone removal.[7] Two surgical approaches commonly used are enterolithotomy alone or enterolithotomy, cholecystectomy, and fistula closure in a single surgical procedure.[5],[7] The latter technique has the benefit of preventing recurrence of gallstone ileus, cholecystitis, and cholangitis, but carries a higher mortality rate. Given the advanced age and comorbidities in these patients, the decision of which surgical option to pursue must be individualized.[5]
| Conclusion | | |
Gallstone ileus can be difficult to diagnose. Given a mortality rate of 7.5–15%, the diagnosis should be considered early in elderly patients and in those without history suggesting another cause of mechanical obstruction.[2],[3],[4] Initial management should focus on fluid resuscitation, correction of metabolic derangements, and surgical evaluation.
Financial support and sponsorship
Nil.
Conflicts of interest
Manish Garg serves as a section editor for the Images in Academic Medicine section of the International Journal of Academic Medicine.
| References | | |
| 1. | Taylor MR, Lalani N. Adult small bowel obstruction. Acad Emerg Med 2013;20:528-44.  |
| 2. | Lassandro F, Gagliardi N, Scuderi M, Pinto A, Gatta G, Mazzeo R. Gallstone ileus analysis of radiological findings in 27 patients. Eur J Radiol 2004;50:23-9. |
| 3. | Zaliekas J, Munson JL. Complications of gallstones: The Mirizzi syndrome, gallstone ileus, gallstone pancreatitis, complications of “lost” gallstones. Surg Clin North Am 2008;88:1345-68, x. |
| 4. | Ayantunde AA, Agrawal A. Gallstone ileus: Diagnosis and management. World J Surg 2007;31:1292-7. |
| 5. | Masannat Y, Masannat Y, Shatnawei A. Gallstone ileus: A review. Mt Sinai J Med 2006;73:1132-4. |
| 6. | Key A, Dawkins A, DiSantis D. Rigler's triad. Abdom Imaging 2015;40:229-30. |
| 7. | Cooperman AM, Dickson ER, ReMine WH. Changing concepts in the surgical treatment of gallstone ileus: A review of 15 cases with emphasis on diagnosis and treatment. Ann Surg 1968;167:377-83. |
[Figure 1]
[Table 1]
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