Gall stone ileus as a cause of intestinal obstruction in an obese

elderly male

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Case Report

Gall stone ileus as a cause of intestinal obstructionin an obese elderly male

Vachan Subhash Hukkeri*, Subhash Mishra, Md Qaleem, Sudipto De,Purak Mishra, Rajiv Shandil, Deepak Govil, Ajay Kumar

Department of GI Surgery, Indraprastha Apollo Hospital, Saritha Vihar, New Delhi, India

a r t i c l e i n f o

Article history:

Received 14 February 2015

Accepted 29 April 2015

Available online xxx

Keywords:

Gall stone ileus

Intestinal obstruction

Rigler's triad

Cholecysto-enteric fistula

* Corresponding author. Indraprastha Apolloþ91 9036360278 (mobile).

E-mail addresses: vachan_sh@rediffmail.http://dx.doi.org/10.1016/j.apme.2015.04.0040976-0016/Copyright © 2015, Indraprastha M

Please cite this article in press as: Hukkeri VMedicine (2015), http://dx.doi.org/10.1016/j.

a b s t r a c t

We present a case of 87-year-old overweight male who presented to us with intestinal

obstruction. He was found to have the classical sings of gall stone ileus (pneumobilia, in-

testinal obstruction & gall stones in the distal ileum). He was managed with a single stage

procedure. Here we also describe the available literature and the various treatment options

available for the same.

Copyright © 2015, Indraprastha Medical Corporation Ltd. All rights reserved.

1. Introduction

Gallstone ileus is a rare cause of intestinal obstruction and is

responsible for 1e4% of all cases of small bowel obstruction

and 25% of nonstrangulated small bowel obstructions in those

over 65 years of age. This data is from studies in 1960's to

1980's and no recent literature incidence of gall stone ileum is

available from the laparoscopic cholecystectomy era. Gall

stone ileus carries a high morbidity and mortality in the

elderly population because of the associated comorbidities

and the delay in diagnosis in most cases. The optimal surgical

management often depends on the physiological state of the

patient.

Hospital, GI Surgery, Sari

com, gourihukkeri@gmai

edical Corporation Ltd. A

S, et al., Gall stone ileus asapme.2015.04.004

2. Case report

A 87-year-oldmale presented to Indraprastha Apollo Hospital,

Delhi with complaints of obstipation since 10 days. He was

nondiabetic, normotensive with a BMI of 28.3. He had history

of meningioma at CP angle for which Gamma Knife surgery

was done successfully 10 years ago. Following this he was in

good health with no medical comorbidities. He also com-

plained of distension of abdomen with vomiting since last 10

days. He was diagnosed with cholelithiasis 4 years back for

which no surgery was done. On examination his vitals were

stable and he was afebrile. On abdominal examination,

distension was noted with diffuse mild tenderness and

ta Vihar, Mathura Road, Delhi, 110076, India. Tel.: þ91 9910369502,

l.com (V.S. Hukkeri).

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a cause of intestinal obstruction in an obese elderly male, Apollo

Fig. 2 e Presence of air in the biliary tree, suggestive of

cholecystoduodenal fistula.

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exaggerated bowel sounds. On investigation his complete

blood counts and renal function tests were within normal

limits. His liver function tests showed raised SGOT/SGPT (184/

302). Plain X-ray abdomen showed dilated bowel loops. Ul-

trasound abdomen showed dilated bowel loops with echo-

genic shadows in distal ileum. CECT abdomen was done,

which showed features suggestive of intestinal obstruction

with hyper dense structures in the lumen of distal ileum

(Fig. 1). Air in the biliary tree was also seen with presence of?

cholecystoduodenal fistula (Fig. 2).

The diagnosis of gall stone ileuswas confirmedon the basis

of the above findings. The patient was thus taken for lapa-

rotomy after adequate preoperative preparation. On laparot-

omy dilated small bowel up till distal ileum was noted. Two

hard roundmobile masses were felt in the distal ileum (Fig. 3).

The two stones were milked proximally and extracted by

an enterotomy done along the antimesenteric border (Figs. 4

and 5). The enterotomy was then closed transversely. The

cholecystoduodenal fistula was identified and divided by

sharp dissection. The duodenal opening was closed with

omental flap and cholecystectomy was done. Postoperatively

mild duodenal leak was noted on POD 3 which closed with

conservativemanagement. Hewas discharged on POD 9 and is

presently symptom free.

Fig. 3 e Two spherical solid masses present in the distal

ileum.

3. Discussion

Mechanical intestinal obstruction due to a gall stone impacted

in the gastrointestinal tract is called gall stone ileus. The

pathogenesis of gallstone ileus usually involves an episode of

acute cholecystitis with subsequent adhesions, inflammation

and fistula formation into the adjacent bowel.1,2 Chol-

ecystoenteric fistula is seen in less than 1% of gallstone cases.3

Cholecystoduodenal fistula is the most common, accounting

for 60e86%.1,4 The clinical presentation is that of intestinal

obstruction which can be either acute, intermittent or

chronic.3 The obstruction is characterised as tumbling in na-

ture.5,6 The site of impaction of the gallstone is the terminal

ileum and ileocecal region in 50e75%, proximal ileum and

jejunum in 20e40% and the rest constitute <10%.2,7 Diagnosis

is usually difficult as the classical Rigler's triad (pneumobilia,

Fig. 1 e Hyperdense spherical structure seen in the distal

ileum.

Please cite this article in press as: Hukkeri VS, et al., Gall stone ileus asMedicine (2015), http://dx.doi.org/10.1016/j.apme.2015.04.004

intestinal obstruction and aberrant gallstone location) is seen

in only 40e50% of plain abdominal X-rays.7 The other asso-

ciated findings may be: change in location of a previously

observed stone or second air fluid level in right upper quad-

rant suggestive of air in gall bladder.8,9 CT scan is better than

USG abdomen as it also defines the fistula tract in most cases

along with the above mentioned findings.10 Treatment is

Fig. 4 e Enterotomy on the antimesenteric border of ileum.

a cause of intestinal obstruction in an obese elderly male, Apollo

Fig. 5 e Stones being extracted through the enterotomy.

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aimed at relieving the obstruction by extracting the stone. The

various treatment option proposed are:

1) Enterolithotomy alone

2) Enterolithotomy with cholecystectomy performed later

(two stage procedure)

3) Enterolithotomy with simultaneous cholecystectomy and

fistula closure (one stage procedure).

Enterolithotomy involves milking the gall stone proximal

to its obstruction, making a 2e3 cm longitudinal enterotomy

on the ileum and extracting the stone with transverse closure

of the defect. It is associated with a recurrence rate of about

8.2%, with 52% of the recurrences occurring in first month and

the rest within 2 years. There also remains the risk of chole-

cystitis, cholangitis and gall bladder carcinoma.11 Enter-

olithotomy with subsequent cholecystectomy and fistula

repair has a mortality of 0% and can be considered as a

feasible option considering the low recurrence rates of gall-

stone ileus.3

Single stage procedure has an associatedmortality of 16.9%

and can be safely advocated in a select group of patients. A

thorough search of the rest of the bowel and CBD should be

done to prevent missing any residual stones in either.4 In case

of an impacted stone with signs of irreversible ischaemia

resection and anastomosis of bowel may be required. Till date

no randomised controlled trial has been done to compare the

above mentioned surgical procedures.12

Overall gallstone ileus remains a relatively rare cause of

small bowel obstruction with a higher morbidity and

Please cite this article in press as: Hukkeri VS, et al., Gall stone ileus asMedicine (2015), http://dx.doi.org/10.1016/j.apme.2015.04.004

mortality in elderly patients. The exact incidence of gall stone

ileus in the era of laparoscopic cholecystectomy is not avail-

able, but is certainly less than before when cholecystoenteric

fistula could be considered as a natural progression of the

disease. The treatment of gall stone ileus should be individ-

ualised depending on the general condition of the patient.

Enterolithotomy alone can be offered to those with relatively

poor general condition after adequate stabilisation. One stage

procedure can be offered to those in a better physiological

state.1,2,4,5,7,12

Conflicts of interest

All authors have none to declare.

r e f e r e n c e s

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2. Glenn F, Reed C, Grafe WR. Biliary enteric fistula. Surg GynecolObstet. 1981;153:527e531.

3. Kasahara Y, Umemura H, Shiraha S, Kuyama T, Sakata K,Kubota H. Gallstone ileus. Review of 112 patients in theJapanese literature. Am J Surg. 1980;140:437e440.

4. Reisner RM, Cohen JR. Gallstone ileus: a review of 1001reported cases. Am Surg. 1994;60:441e446.

5. Warshaw AL, Bartlett MK. Choice of operation for gallstoneintestinal obstruction. Ann Surg. 1966;164:1051e1055.

6. Raiford TS. Intestinal obstruction due to gallstones (gallstoneileus). Ann Surg. 1961;153:830e838.

7. Clavien PA, Richon J, Burgan S, Rohner A. Gallstone ileus. Br JSurg. 1990;77:737e742.

8. Rigler LG, Borman CN, Noble JF. Gallstone obstruction:pathogenesis and roentgen manifestation. JAMA.1941;117:1753e1759.

9. Balthazar EJ, Schechter LS. Air in gallbladder: a frequentfinding in gallstone ileus. AJR Am J Roentgenol.1978;131:219e222.

10. Lassandro F, Gagliardi N, Scuderi M, Pinto A, Gatta G,Mazzeo R. Gallstone ileus analysis of radiological findings in27 patients. Eur J Radiol. 2004;50:23e29.

11. Doogue MP, Choong CK, Frizelle FA. Recurrent gallstone ileus:underestimated. Aust NZ J Surg. 1998;68:755e756.

12. Ayantunde AA, Agrawal A. Gallstone ileus: diagnosis andmanagement. World J Surg. 2007;31:1292e1297.

a cause of intestinal obstruction in an obese elderly male, Apollo

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