Rare case of gallstone ileus reported in BMJ
Gallstone ileus is a rare cause of bowel obstruction with high mortality and it is usually preceded by cholecystitis, which facilitates the adherence of the inflamed gallbladder to the adjacent gut. If the gallbladder has an impacted gallstone, this could erode through the wall of the gallbladder into the gut, forming a cholecystoenteric fistula. As they pass through the bowels, the larger stones (>2.5 cm) can get impacted, mainly in the terminal ileum, causing mechanical obstruction.
The authors have reported an interesting case of gallstone ileus as it developed in an 88-year-old woman. The patient was admitted with acute cholecystitis and a CT scan showed a 3 cm stone in a thick-walled gallbladder (figure 1). She was successfully treated conservatively and a decision was made not to offer her an elective cholecystectomy as she was deemed unfit for the operation.
Interestingly, only 3 weeks later, the patient was readmitted with a 3-day history of severe colicky abdominal pain and vomiting. An urgent CT scan of the abdomen and pelvis showed that the recently found large gallstone had migrated into the gut and impacted in the ileum causing small bowel obstruction (figure 2).
The patient was taken to the theatre the same day and underwent a laparotomy and extraction of the gallstone via enterotomy (figure 3). She had an uneventful recovery and remained well at 3-month follow-up.
Learning points
Gallstone ileus should be considered in all elderly patients with a significant history of cholelithiasis presenting with features of bowel obstruction.
The decision to expectantly manage patients with gallstones based on their fitness level should be carefully taken particularly in those with known large gallstones, as related complications, including gallstone ileus, may be fatal in these frail patients.
The mainstay of treatment in unfit patients is to relieve the bowel obstruction via enterotomy and avoid a prolonged operation.
For more details click on the link: doi:10.1136/bcr-2015-212972
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