Selected Articles from the
Journal Abdominal Surgery

This article originally appeared in the Winter 2009 / Spring 2010 issue of the Journal.

Recurrent Gallstone Ileus, Case Report and Literature Review

Mr. Shahme Farook (MBChB, BSc [Hons], MRCS)
Senior House Officer

Mr. John Harrison (MBChB, FRCS)
Consultant General Surgeon

Department of Surgery,
Harrogate and District NHS Foundation Trust,
Lancaster Park Road, Harrogate,
HG2 7SX, United Kingdom

Corresponding author:
Mr J.D Harrison
Consultant General Surgeon
Department of Surgery,
Harrogate and District NHS Foundation Trust,
Lancaster Park Road, Harrogate,
HG2 7SX, United Kingdom
Tel: 0044-1423-553509
Fax: 0044-1423-553466
E-mail: JON.HARRISON@hdft.nhs.uk

KEY WORDS
Gall stone ileus, Computed Tomography (CT), Enterotomy, Cholecysto-duodenal fistula, Laparotomy

ABSTRACT
Recurrent gallstone ileus is a clinical and a radiological diagnosis which needs to be addressed appropriately to minimize both mortality and morbidity. This case report identifies a patient with recurrent gallstone ileus and explores the clinical and radiological modalities of diagnosis and how best to manage these patients in a clinical setting.

SUMMARY
A rare case of a recurrent gallstone ileus is identified and the diagnosis and management of such patients is discussed.

Figure 1. Fistulography performed though the 2 mm umbilical orificce, demonstrating the umbilicoileal fistula diagnostic of the patent omphalomesentecic duct.

INTRODUCTION
Recurrent gallstone ileus is an infrequent diagnosis which embarrasses both radiologists and surgeons alike from time to time despite the availability of modern imaging modality. However careful inspection of the stone extracted from bowel, gentle palpation of the gall bladder during surgery and thorough look at the images preoperatively can easily obviate the need for the second operation. This case report has identified a patient with recurrent gallstone ileus and evaluates the management.

CASE REPORT
A 73 year old gentleman with a history of gallstones was admitted with a sudden onset of right upper quadrant pain. The pain was sharp, colicky in nature and radiated to the back. Except for a raised leucocyte count and CRP of 40, all other investigations were within normal limits. Two days later the patient complained of increased pain in his left iliac fossa and examination confirmed tenderness and guarding with reduced bowel sounds. Abdominal X-rays confirmed sub acute small bowel obstruction but no pneumobilia or gallstones were seen. Computed Tomography (CT) of the abdomen carried out the following day confirmed the diagnosis as gallstone ileus (Figure 1a). Laparotomy, enterotomy and removal of gall stone was carried out successfully and the patient made an uneventful recovery.

Three months later the patient presented with generalized abdominal pain with guarding and an abdominal X-ray confirmed small bowel obstruction. The CT scan confirmed the diagnosis as recurrent gallstone ileus (Figure 1b). He underwent laparotomy during which two large gall stones were removed through enterotomy. The gall bladder was fixed to the duodenum and surgical intervention to repair the fistula was not considered.

DISCUSSION
The term gallstone ileus, which was coined by Bartholini in 1654 ^{1, 2,} is a mechanical intestinal obstruction which mainly affects the small intestine. It is produced by one or more gallstone becoming impacted within the lumen³. There is usually a biliary enteric fistula with significant inflammation4 (Figure 2). This condition is more common among the elderly population and accounts for 2-5% of all cases of intestinal obstruction ^{3, 4, 5, 6}. The incidence is high as 25% of all cases of intestinal obstruction in patients over 65 years of age ^{1, 7,} and therefore seems to be encountered more often than usual with the increase in life expectancy² but increased prevalence of cholecystectomy in recent years has a negating effect 4. The female to male ratio varies from 1.1:1 to 9:1 ³. Recurrence of gallstone ileus seems to be a rare incidence and the data available is limited.

Figure 3. Surgical demonstraton of vermiform apendix (A) and patent omphalomesentecic duct (B) with the base in the anti-mesenteric border of the ileum.

Tan et al identifies peri-operative mortality to be high as 12-17% and the two contributing factors towards this increase has been identified as elderly patients with multiple co-morbid factors making up the bulk of the patient population and the difficulty in diagnosis leading to delay in treatment ^{2, 4}. Retrospective analysis by van Hillo et al identified moderate dehydration and electrolyte imbalance in all their patients and a mean diagnosis time interval of 6 days ³. Once the diagnosis is made, the surgical option available seems to have divided the surgical community into two schools of thought. Since the incidence of this condition is very rare, any randomized control trial seems to be futile and studies available are mainly retrospective studies with the total population being well below levels of any statistical significance.

As the calculus passes down the intestinal tract it results in intermittent symptoms due to short lived partial obstruction defined as the "Tumbling Phenomenon" ⁶. The size of the stone increases as a result of sedimentation of bowel contents, and once the stone becomes firmly impacted it results in the manifestation of the symptoms of complete obstruction ³.

Recurrent enteric gallstone obstruction can be attributed to an overlooked intra-enteric stone or subsequent passage of another gallstone through the cholecysto-enteric fistula ⁴. These patients tend to present with a small bowl obstruction usually within a few days to months after the initial surgery ⁸. The diagnosis would mainly be made on history, clinical examination and prompt radiological investigation.

History of recent gallstone ileus should promptly alert the surgeon of the diagnosis. However if the time frame was lengthy radiological intervention should be actively sought to exclude any other abnormalities but should not delay in resuscitating the patient and arrangements being made for possible surgery.

When radiological studies are undertaken, presence of Rigler’s triad^{6, 9} of pneumobilia, gallstones and bowel dilatation together with the history of previous gallstone ileus would improve the diagnosis quite considerably. However these radiological features are only seen on plain radiography in 30-35% of the patients ^{4, 6}. Although an upper gastrointestinal contrast study would mainly demonstrate a gallstone or the presence of a biliary enteric fistula ², if it has not been surgically dealt with during previous laparotomy. Furthermore co-morbidity of the patient at the time of presentation could be a hindrance towards carrying out a successful contrast study and could result in delay in any early surgical intervention.

The role of the CT scan in small obstruction has gained popularity 2 over the past few years due to its non-invasive nature, feasibility of early diagnosis and widespread availability. Studies have identified high accuracy for CT scan based diagnosis as it is more sensitive than plain radiography in identifying features of Rigler's triad. Even radiolucent stones can be diagnosed with confidence by using CT Scans10. Therefore the validity of a CT scan as tool for diagnosis for gallstone ileus is high in sensitivity and specificity and would no doubt assist in pre-operative planning ⁴.

In the past up to 50% of the diagnosis was made during the laparotomy and at present it remains the mainstay of treatment for gallstone ileus. Studies have identified that the obstruction was mainly in the terminal ileum^{3, 4,} where the diameter of the obstructing calculi was greater than 2.5 cm but a stone of up to 17.7 cm has been reported in earlier studies ⁴.

Obstruction by an ectopic gallstone within the stomach, jejunum and colon have been reported with an obstruction within the duodenum constituting to Bouveret's syndrome have been documented⁴. Once the laparotomy is made the entire small bowel should be examined carefully to exclude any other stone or remnant of the stone as multiple gallstones are found in 3-15% of patients with gallstone ileus³. Generally if the stone has a facet another stone is likely and in a case report by Keogh et al the second stone was missed despite careful examination⁶. Intra abdominal Ultrasound scanning has been used to aid the process of scanning for any further stone and also to visualize the gallbladder to exclude any further gallstones which could possibly cause further obstruction within the enteral lumen.

Extraction of the stone could be carried through enterotomy which has been the common mode of delivery of the stones or the remnants. If the stone was closer to the proximal part of the small bowel it is possible to attempt to deliver the stone through the site of cholecysto-duodenal fistula if surgery was to be carried out to surgically discontinue the fistula and attempt cholecystectomy and repair of the duodenum. Furthermore manual propulsion of the calculus into the caecum has been successfully carried out but it does carry the risk of undetected subserosal ruptures of the bowel wall. Crushing of the stone in-situ has not been recommended as it could cause damage to the bowel wall warranting bowel resection3. Hagger et al reports of laparoscopic enterolithotomy for gallstone ileus but the patient developed recurrent small bowel obstruction due to the presence of a second gallstone which questions the ability of this technique to examine the bowel for multiple gallstones ¹¹.

The controversy surrounding the surgical intervention involves whether or not one should continue to perform "one stage" procedure of cholecystectomy and repair of the duodenum as first suggested by Holz in 1920. The rationale was to eliminate a fistula which would be a possible source of further recurrence of a gallstone ileus or even a higher incidence of carcinoma of the gall bladder ^{1, 3}. This surgical debate has been presented in a few retrospective studies over the past few years and none have led to any widely accepted practice of treatment in gallstone ileus. The population group for gallstone ileus being within the average age group of 65-75; would have an unfavorable outcome following surgery due to their pre-operative co-morbid factors and their physiological status prior to surgery³,which has been recorded to be as high as 10-25%⁷. Furthermore generalized inflammation identified within the right upper quadrant in the abdominal cavity would add to post surgical co-morbidity and mortality if disturbed and, it does not warrant for any intervention at the time of surgery apart from enterotomy and removal of stone to relieve the obstruction.Most fistulae tend to close spontaneously once the stone has passed 3 and leaving a patent fistula could increase the possibility of a recurrent gallstone ileus by 2-5% but review of studies on recurrent gallstone ileus by 4 has increased the risk 8.2% ⁴.

After evaluating studies available on gallstone ileus and recurrent gallstone ileus, it can be concluded that most recent studies have identified laparotomy and enterotomy alone in patients with higher intra and post-operative risks and to consider further surgical intervention at a later stage.

Gallstone ileus is a rare cause of bowel obstruction but constitutes to a greater percentage in the elderly population. Therefore prompt diagnosis aided by clinical and radiological examination should be followed up by optimizing the patient for urgent laparotomy and enterotomy, for the removal of the obstructing gallstone. Debate regarding extensive surgery to correct the fistula should not be a cause for the delay in surgery as it could always be considered at a latter stage.

Acknowledgement: The authors wish to thank Gordon Museum (Guy’s, King’s & St.Thomas’s Hospitals Medical & Dental School, United Kingdom) for providing the photograph of the anatomical specimen.

REFERENCES

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3. van Hillo M, van der JA, et al. Gallstone obstruction of the intestine: An analysis of ten patients and a review of the literature. Surgery. 1987; 101: 273-276.

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11. Hagger R, Sadek K, Singh K. Recurrent small bowel obstruction after laparoscopic surgery for gallstone ileus. Surgical Endoscopy. 2003; 17: 1679.