Please confirm topic selection

Are you sure you want to trigger topic in your Anconeus AI algorithm?

Please confirm action

You are done for today with this topic.

Would you like to start learning session with this topic items scheduled for future?

Updated: Dec 14 2021

Gallstone Ileus

  • Snapshot
    • An 85-year-old woman presents to the emergency department with nausea, vomiting, and abdominal pain. She states her symptoms started 1 week ago. She describes the pain as crampy, intermittent, and localized to the right upper quadrant (RUQ). She has a history of hypertension and cholelithiasis. On physical exam, mucous membranes are dry and abdominal RUQ is tender to palpation. Abdominal radiograph reveals dilated loops of small bowel and gas in the biliary tree.
  • Introduction
    • Clinical definition
      • mechanical obstruction of the bowel by a large gallstone
  • Epidemiology
    • Demographics
      • most commonly seen in elderly women
    • Risk factors
      • elderly
      • chronically inflamed gallbladder
      • gallstones > 2 cm
  • etiology
    • Pathogenesis
      • caused by perforation and cholecystenteric fistula formation connecting the an inflamed gallbladder with the bowel
        • most common sites are the ileocecal valve and the terminal ileum
  • Presentation
    • Symptoms
      • episodic bowel obstruction
        • nausea
        • vomiting
        • constipation
        • abdominal pain
        • abdominal distension
      • may be seen in severely ill patients with altered mental status who may not be able to localize pain
    • Physical exam
      • fever
      • abdominal tenderness
      • abdominal distension
      • signs of dehydration
  • imaging
    • Abdominal computed tomography (CT)
      • gold standard for diagnosis
        • Riger triad
          • pneumobilia
            • air in the biliary tract
          • intestinal obstruction
          • obstructing/ectopic gallstones
    • Abdominal ultrasound
      • may be more sensitive for pneumobilia
      • may help identify location of gallstones
        • but intestinal gas can reflect ultrasound waves, which limits gallstone visualization
    • Abdominal radiograph
      • if CT or ultrasound not available
  • Studies
    • Diagnostic testing
      • studies
        • cholescintigraphy/hepatobiliary iminodiacetic acid (HIDA) scan
          • consider if CT is not diagnostic
  • Treatment
    • Management approach
      • primarily surgical
        • to address intestinal obstruction, cholelithiasis, and biliary-enteric fistula
    • First-line
      • enterolithotomy (enterotomy with stone removal)
        • may require bowel resection where there is perforation, significant ischemia, or a gallstone that cannot be dislodged
    • Second-line
      • cholecystectomy and biliary-enteric fistula closure
        • indication
          • in low-risk patients
            • can undergo biliary procedure same time as enterolithotomy
          • in high-risk patients (i.e., American Society of Anesthesiologists (ASA) class III or IV, patients in shock, or who have significant intra-abdominal inflammation/adhesion)
            • can be performed at a later time after enterolithotomy if recurs or when condition permits
    • Other treatments
      • prophylactic antibiotics
        • indication
          • for peri-operative period
          • i.e., cefoxitin
      • lithotripsy
        • indication
          • if poor surgical candidate
  • Complications
    • Mortality
      • higher risk compared with other causes of mechanical bowel obstruction
        • majority of patients with gallstone ileus are older and with serious concomitant medical conditions
    • Recurrent gallstone ileus
      • especially with enterolithotomy alone
1 of 0
Private Note

Attach Treatment Poll
Treatment poll is required to gain more useful feedback from members.
Please enter Question Text
Please enter at least 2 unique options
Please enter at least 2 unique options
Please enter at least 2 unique options