Gallstone Ileus: Report of Two Cases and Review of the Literature

Abstract: Gallstone ileus is a rare and serious complication of gallstone disease, presenting as a mechanical intestinal obstruction caused by an ectopic gallstone. It mainly affects elderly individuals and carries a high mortality rate because of the advanced age of patients and the associated comorbidities. It results from the formation of a bilio-enteric fistula. A large gallstone may then migrate into the intestine and become impacted, most often in the terminal ileum. Symptoms are often misleading and intermittent, which may delay diagnosis. Computed tomography (CT) is the imaging modality of choice. Despite some limitations, it allows confirmation of the diagnosis by visualizing Rigler’s triad, consisting of pneumobilia, intestinal obstruction, and an impacted stone at the transition zone. Treatment is mainly surgical and is essentially aimed at relieving the obstruction. Several strategies are debated, with enterolithotomy alone occupying a predominant place. A rapid diagnosis, facilitated by CT, and appropriate surgical intervention, most often a simple enterolithotomy, are essential to improve patient prognosis. We report two cases of gallstone ileus. The first concerned an 81-year-old woman with hypertension and diabetes, followed for gout, who presented with epigastric pain and vomiting evolving over 5 days. Ultrasound was performed and showed fluid-filled dilated small-bowel loops without wall thickening or visible obstruction, and a contracted gallbladder with no dilatation of the intrahepatic bile ducts. Abdominal computed tomography (CT) was requested and confirmed obstruction proximal to a stone in the last ileal loop, associated with thickening of the gallbladder wall and pneumobilia, suggesting chronic cholecystitis with a biliary-enteric fistula. The patient underwent laparotomy with a one-stage procedure; exploration did not demonstrate a stone in the ileum, and cholecystectomy with fistula repair was performed. It was concluded that the stone had passed into the colon. The patient was subsequently monitored, with a favorable course and notably no sign of recurrence. The second case concerned a 65-year-old man who presented to the emergency department with a picture of intestinal obstruction; emergency abdominal CT was performed and the diagnosis of gallstone ileus was established. He underwent laparotomy with a one-stage procedure and extraction of the stone by enterolithotomy. The postoperative course was favorable. The literature on gallstone ileus consists mainly of small series and case reports. We performed a literature review focusing on the relevant points of diagnosis and management of this condition.