CIRUGIA Y CIRUJANOS REVIEW ARTICLE

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Gallstone ileus, surgical management review
Íleo biliar, revisión del manejo quirúrgico
Marcos I. Salazar-Jiménez1*, Javier Alvarado-Durán2, Mónica R. Fermín-Contreras3,
Fernando Rivero-Yáñez1, Arianne I. Lupian-Angulo1 and Antonio Herrera-González1
1
Department of General Surgery; 2Department of General Surgery, Sanatorio Durango; 3Endoscopy Department. Hospital Central Norte PEMEX,
Mexico City, Mexico

Abstract

Background: Gallstone ileus (GI) represents a rare cause of mechanical intestinal occlusion, which is caused by the impaction

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of a gallstones at the gastrointestinal tract, being most frequently the terminal ileum; its etiology is due to the passage of a
calculum through a biliary-enteric fistula. Due to its low incidence, diagnostic suspicion and adequate initial surgical treatment
are essential for an adequate clinical evolution. Objective: A bibliographic review on the current surgical management of GI
was carried out and exemplified by the presentation a clinical case. Clinical case: 78-year-old male with bowel obstruction,
upon undergoing a CT scan, a gallstone at the level of distal ileum is displayed, therefore, an exploratory laparotomy (ex lap)
is performed with enterotomy and extraction of the calculus. The patient bestowed adequate postoperative clinical evolution,
and the presence of a cholecystoduodenal fistula is documented by an upper endoscopy. Discussion: GI represents an un-
common pathology, however, there is discrepancy in the literature regarding the initial surgical management, especially in
whether or not a biliary procedure should be associated with emergency enterolithotomy. Conclusion: GI is associated with
complications secondary to diagnostic delay and its late surgical resolution, although the initial treatment is aimed at resolving
the intestinal obstruction through enterotomy and gallstone extraction, there is controversy regarding the preferred time for
cholecystectomy and repair of biliary-enteric fistula, being the two-stage surgery the surgical procedure of choice, especially
in patients with a high risk of complications.

KEY WORDS: Gallstone ileum. Surgical management. Cholecystoduodenal fistula. Intestinal occlusion.

Resumen

Antecedentes: El íleo biliar (IB) es una causa poco frecuente de oclusión intestinal mecánica, causado por la impactación de
un cálculo biliar en el tubo digestivo, siendo la localización más frecuente el íleon terminal; se debe al paso de un cálculo a
través de una fístula bilioentérica. Debido a su baja incidencia, la sospecha diagnóstica y el tratamiento quirúrgico inicial
adecuado son de gran importancia para la evolución clínica. Objetivo: Realizar una revisión bibliográfica sobre el manejo
quirúrgico actual del IB y ejemplificarlo mediante la presentación de un caso clínico. Caso clínico: Varón de 78 años con
cuadro de oclusión intestinal, con presencia de cálculo biliar en el íleon distal por tomografía. Se realiza laparotomía explora-
dora con enterotomía y extracción del cálculo. Cursa con adecuada evolución posquirúrgica, documentándose fístula colecis-
toduodenal por panendoscopia. Discusión: El IB es una patología poco común, por lo cual existe discrepancia en cuanto al
tipo de manejo quirúrgico ideal, sobre todo en si se debe o no asociar un procedimiento biliar a la enterolitotomía de urgencia.
Conclusión: El IB se asocia a complicaciones secundarias al retraso diagnóstico y a una mala elección de la técnica quirúr-
gica inicial. Si bien el tratamiento está encaminado a resolver la obstrucción intestinal mediante enterotomía y extracción del
cálculo biliar, existe controversia en cuanto al tiempo preferido para realizar la colecistectomía y la reparación de la fístula

Correspondence:
*Marcos I. Salazar-Jiménez
Valladolid 40 interior 304 A
Col. Roma norte, Del. Cuauhtémoc Date of reception: 01-04-2018 Cir Cir. 2018;86:163-167
C.P. 06700, Ciudad de México, México Date of acceptance: 20-04-2018 Contents available at PubMed
E-mail: marcos.salazarj@gmail.co DOI: 10.24875/CIRUE.M18000026 www.cirugiaycirujanos.com

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 Cirugía y Cirujanos. 2018;86

bilioentérica, siendo la cirugía en dos tiempos el procedimiento quirúrgico de elección, sobre todo en pacientes con alto ries-
go de complicaciones.

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PALABRAS CLAVE: Íleo biliar. Manejo quirúrgico. Fístula colecistoduodenal. Oclusión intestinal.

Introduction Diagnostic suspicion is of paramount importance for

timely management. Clinically, the Mordor triad is des-
cribed, which includes known cholelithiasis diagnosis,
Gallstone ileus (GI) is described as a mechanical
clinical signs of acute cholecystitis and data consis-
intestinal obstruction caused by impaction of one or
tent with intestinal obstruction. As part of the paracli-
more gallstones on any part of the digestive tract, main-
nical tests, Rigler’s triad is described in abdominal
ly in the small intestine, with the most common site
X-ray, which involves the presence of radiopaque sto-
being the distal ileum1. The etiology is secondary to the
nes (less than 10% of cases), pneumobilia (Got-
passage of a gallstone from the bile ducts or the
ta-Mentschler sign) and intestinal loop distension, with
gallbladder to the gastrointestinal tract through an en-
the diagnosis being established in the presence of two

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terobiliary fistula (with the most common cause being
of these three radiological signs. When adding galls-
cholecystoduodenal fistula), which is formed by the
tone position change in a second radiograph, Rigler’s
presence of recurrent episodes of acute cholecystitis
tetrad is completed, which has higher diagnostic sen-
or secondary to Mirizzi syndrome, where there is chro-
sitivity. The Petren sign corresponds to the passage
nic perivesicular inflammation that generates adheren-
ces between the bile duct and the gastrointestinal tract, of contrast medium into the biliary tract8-10.
and subsequent to that, the pressure exerted by the Computed tomography with contrast medium is con-
gallstone causes necrosis of the vesicular wall, thus sidered the method of choice for the diagnosis of GI,
eroding it and causing bilioenteric communication2-4. with a sensitivity higher than 90%. It is important to
GI accounts for 0.3 to 0.5% of cholelithiasis compli- rule out the most common causes of intestinal occlu-
cations, with an incidence of 3/100,000 hospitaliza- sion, such as adherences, incarcerated/strangulated
tions associated with biliary pathology, and is more hernia, abdominal tumor, volvulus, etc.7,8,11.
common in the female gender at a 3.5:1 ratio, with GI treatment is aimed at resolving intestinal obstruc-
higher incidence in people older than 65 years. It ac- tion, after patient stabilization. Surgical treatment re-
counts for 0.5% of the causes of small bowel obstruc- mains the management of choice in these patients
tion, affecting mainly patients older than 65 years with and is divided in two stages1,3,8:
multiple comorbidities, and with a mortality 5 to 10- – Stage 1: laparotomy with longitudinal enterolitho-
fold higher than the rest of the causes of small bowel tomy at the antimesenteric border, after milking
obstruction5,6. the stone in the proximal area, with transversal
The size of the stone is significant to triggering the closure being performed to avoid stenosis. Milking
disease. It should measure at least 2 cm in diameter of the gallstone to the colon is not recommended
(2.5 cm on average) to cause obstruction (90% of because it is associated with mucosal injury and
cases). The site where the calculus is lodged will in- rupture of the serosa, which may go unnoticed1,2.
duce different clinical scenarios, including Barnard’s A systematic examination of the entire intestine is
syndrome, where the stone obstructs the ileocecal carried out in search of gallstones, which can be
valve, manifesting as a classic intestinal occlusion, found in 3–16% of cases, and can be extracted
sometimes accompanied by jaundice (in less than using the same enterotomy. Most cases of GI re-
15%), characterized by abdominal distension, pain, lapse are associated with unidentified stones on
vomiting, absence of peristalsis, constipation or obs- initial laparotomy. In selected patients, a laparos-
tipation. On the other hand, there is the Karewsky copic approach with eventration of the compromi-
syndrome, which is characterized by chronic presence sed intestinal segment can be performed, which
of intermittent abdominal pain, caused by the passage entails lower morbidity and shorter recovery time;
of gallstones to the intestine. Involvement of the colon however, it is considered a technical challenge
is much rarer, which is associated with sites of steno- due to the degree of difficulty1,2.
sis or narrowing secondary to inflammatory bowel – Stage 2: depending on patient risk factors, one
disease2,7-9. of the following options is chosen:
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 M.I. Salazar-Jiménez, et al.: Gallstone ileus

– Observation in those patients at high risk A B

(ASA III or IV), in shock, with multiple adhe-
rences and important intestinal inflammation.

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In case of GI relapse (4.7–17%), a laparos-
copic cholecystectomy should be performed
when patient conditions allow.
– Patients at low risk (ASA I, II) can undergo cho-
lecystectomy and biliary fistula closure the at
the same surgical time of enterolithotomy with
Figure 1. Abdominal tomography, where a 2.5 x 2.4 x 4.4-cm image is
common bile duct exploration if warranted
observed at the level of the jejunum. A: coronal slice. B: sagittal slice.
(one–stage surgery), which reduces recurren-
ce, prevents malabsorption and weight loss,
A B
avoids cholecystitis and cholangitis, and de-
creases the risk of gallbladder carcinoma1,2,8,12.
On occasions, endoscopic management with me-

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chanical fragmentation lithotripsy can be used as an
alternative for patients who are not candidates for
surgical management12,13.
This is a pathology that mainly affects older adults,
who usually have multiple comorbidities, with an esti-
mated mortality of 4.5 to 25%, which is 5 to 10-fold
higher in comparison with the rest of small bowel
obstruction causes1,2. Figure 2. A: calculus in the jejunum with loop dilation at the proximal
level. B: jejunum longitudinal enterolithotomy with gallstone extraction.
Clinical case

This is the case of a 78-year-old male patient who

was admitted by referral from the emergency depart-
ment. He had a 24-hour history of signs and symp-
toms characterized by colicky abdominal pain at the
mesogastrium, with an intensity of 7 out of 10 on the
visual analogue scale and diffuse irradiation to the
rest of the abdomen, which was associated with into-
lerance to the oral route and with the presence of
vomiting, initially of gastric content, but that later be-
came fecaloid. He reported having had a decrea-
sed-consistency stool prior to his admission.
Relevant past medical history included high blood
pressure diagnosed 16 years prior on management
with amlodipine (5 mg/24 h), candesartan (8 mg/12 h)
and metoprolol (25 mg/24 h), and hypothyroidism Figure 3. Control endoscopy with presence of cholecystoduodenal
diagnosed 15 years prior and managed with levothyro- fistula.
xine (100 mg/24 h). He had undergone conventional
appendectomy 6 years prior. He denied past history data consistent with peritoneal irritation; decreased
of trauma, transfusions and drug addiction. He refe- peristalsis was detected in all four quadrants.
rred having been diagnosed with cholelithiasis 6 years Laboratory tests indicated a white blood cell count of
prior due to apparent acute cholecystitis. 14.8 × 103/mL, with neutrophils at 12.7 × 103/mL; lympho-
Relevant findings on physical examination included cytes, 1.2 × 103/mL; hemoglobin, 17.3 g/dL; hematocrit,
abdominal distention with generalized pain with me- 53.3%; platelets, 216 × 103/mL; creatinine, 1.22 mg/dL;
dium pressure and deep palpation, predominantly in BUN, 20.4 mg/dL; urea, 43.7 mg/dL; sodium, 141 mEq/L;
the mesogastrium, without muscle resistance or potassium, 4.4 mEq/L; and chlorine, 99 mEq/L.
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 Cirugía y Cirujanos. 2018;86

GI diagnosis

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Enterotomy with gallstone extraction*
(Exploratory or laparoscopic laparotom)

ASA III/IV
Hemodynamic instability
Low metabolic and
YES
breathing reserve
NO

TWO-STAGE SURGERY ONE-STAGE SURGERY**

Systematic examination of the

rest of the intestine CHOLECYSTECTOMY
And extraction of stones in order CHOLECYSTOSTOMY

INTERVAL
BILIOENTERIC FISTULA REPAIR

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CHOLECYSTECTOMY***
FISTULA REPAIR

Figure 4. Gallstone ileus treatment algorithm.

A nasogastric tube was placed, with the presence Discussion

of fecaloid-type output of approximately 1500 cc being
documented at the moment of placement. Contrasted GI is an infrequent cause of mechanical intestinal
abdominal tomography reported a 2.5 × 2.4 × 4.4-cm occlusion1,2. Clinical suspicion should be present in
heterogeneous image at the level of the ileum, which patients with abdominal pain consistent with acute
caused an up to 4.3 cm dilation of the small bowel cholecystitis and high intestinal occlusion, since the
loops at the level of the jejunum, probably related to most common site of gallstone impaction is the distal
GI, as well as presence of two similar images, smaller ileum. Only patients with alterations in large intestine
in size, at the level of the jejunum, not consistent with normal anatomy (inflammatory bowel disease, neo-
obstruction data (Fig. 1). plasms, etc.) present with data of low intestinal occlu-
Exploratory laparotomy revealed the presence of a
sion due to impaction of the stone at the narrowing
plastron of inflammatory appearance in the hepatic an-
site1,2,4.
gle, with firm adherences of the transverse colon to the
Initial management of patients with GI is always
duodenum, the omentum and the Gleason capsule, wi-
surgical after stabilization (adequate hydration, analge-
thout the gallbladder or the extrahepatic bile duct being
sia, hydroelectrolytic correction, etc.), and is aimed at
able to be visualized. A gallstone of approximately 2.5
resolving the obstruction and preventing complications
× 2.5 × 4 cm in diameter was found at 240 cm from the
such as ischemia of the intestinal wall, perforation, pe-
ligament of Treitz, which caused proximal dilation of the
small intestine loops, without evidence of necrosis of the ritonitis and even death. Enterotomy at the anti-mesen-
wall or disruption of the intestinal serosa. A longitudinal teric border with extraction of the gallstone and
enterotomy was performed on the antimesenteric border transverse closure is the standard emergency manage-
and the stone was extracted after proximal milking at ment; cholecystectomy with resolution of the fistula in
60 cm from the ileocecal valve (Fig. 2 A and B). the same surgical act is reserved for young and clini-
The patient had an adequate clinical evolution, cally stable patients, when their conditions allow it, with
tolerating the oral route 48 hours after the surgical two-step surgery with interval cholecystectomy being
intervention. A subsequent panendoscopy revealed the most recommended approach in the majority of
the presence of a contraction scar and fistula orifice cases3,5.
of approximately 6 mm in diameter, with well-defined,
slightly elevated edges, with edema and hyperther- Conclusions
mia, with a normal vascular pattern, at the level of the
duodenal bulb (Fig. 3), in relation to probable chole- Due to its low incidence, there is no consensus set-
cystoduodenal fistula. ting out the rules for the management to be followed in
166
 M.I. Salazar-Jiménez, et al.: Gallstone ileus

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