Gallstone Ileus

The gallbladder is a pear-shaped organ adherent to the

undersurface of the liver in a groove separating the right and left
lobes
The hepatic artery is to the left of the common duct
The portal vein is posterior and medial

The right hepatic artery usually passes behind the hepatic duct
and then gives off the cystic artery before entering the right lobe
of the liver
Bile is produced at a rate of 500-1500 mL/d by the hepatocytes
and the cells of the ducts
Three factors regulate bile flow : hepatic secretion, gallbladder
contraction, and choledochal sphincteric resistance
Cholecystokinin (CCK) is the major physiologic stimulus for
postprandial gallbladder contraction and relaxation of the
sphincter
About 250-300 mg of bilirubin is excreted each day in the bile
75% of it from breakdown of red cells in the reticuloendothelial
system and 25% from turnover of hepatic heme and
hemoproteins

Cholesterol gallstones result from secretion by the liver of bile

supersaturated with cholesterol
Pigment stones are black to dark brown, 2-5 mm in diameter, and
amorphous
Composed of a mixture of calcium bilirubinate, complex bilirubin
polymers, and bile acids
Bacteria have a primary role in pigment gallstone formation

Gallstone ileus is mechanical intestinal obstruction caused by a

large gallstone lodged in the lumen
It is seen most often in women, and the average age is about 70
The obstructing gallstone enters the intestine through a
cholecystenteric fistula located in the duodenum, colon, or,
rarely, the stomach or jejunum
Stones that cause gallstone ileus are almost always 2.5 cm or
more in diameter

Location of the cholecystenteric fistula in the duodenum, colon, or, rarely, the stomach or
jejunum

Sign and Symptom

The patient usually presents with obvious small bowel
obstruction, either partial or complete
Abdominal pain and vomiting which subside as the
gallstone becomes disimpacted. Hematemesis could
occur as an occasional complication that is due to
hemorrhage at the site of the biliary enteric fistula
Riglers Triad
- Pneumobilia
- SBO (Small Bowel Obstruction)
- Impacted gallstone-usually in the terminal
ileum at ileocecal valve
Physical Examination
The patient may be febrile and often appears dehydrated
Common abdominal signs include distension and
increased bowel sounds
Jaundice is uncommon, occurring in less than 15% of
cases
Diagnosis
The most important diagnostic test is abdominal plain film
Hard to diagnose previous series yield 43% to 73%
diagnosed preoperatively

CT scan highly sensitive and accurate in pre-op diagnosis

of suspected intestinal obstruction

Imaging

Dilated small intestine

Plain films of the abdomen
may show a radiopaque
gallstone
In about 40% of cases,
careful examination of the
film will reveal gas in the
biliary tree

When the clinical picture is

unclear, an upper
gastrointestinal series
should be obtained, which
will demonstrate the
cholecystoduodenal fistula
and verify intestinal
obstruction

Treatment
Relief intestinal obstruction after adequate fluid repletion
Debate involves need for definitive biliary tract surgery
Enterolithotomy alone to relieve obstruction with biliary
tract surgery later (two stage procedure) or to perform
the biliary tract surgery at the same sitting (one stage
procedure)
Two stage: quick relief mechanical obstruction avoid need
fistula exploration and reduces operative time
- Most fistulas close spontaneously if left alone
- Published reports show lower mortality rate
11% in two stage procedure compared to
6.7 % for one stage procedure

One Stage: more technically difficult, reduces occurrence

recurrent gallstone ileus, cholecystitis and cholangitis