Multiple choice in management of gallstone ileus: 2 cases

F. Agri, V. Ott, A. Munday

Objective

Gallstone ileus is an uncommon cause of bowel obstruction. It accounts for 1-4% of all small bowel obstructions 1,2. Women are concerned 3-16 times more than men 3. First described in 1654 4, gallstone ileus involves adhesions between the gallbladder and adjacent bowel structures with a subsequent cholecysto-enteric fistula enlarged by pressure necrosis. The actual mortality reported varies from 12-27% 5. The management strategy of this rare condition remains controversial. We report two well documented cases of gallstone ileus.

Methods

A 82 year old female and a 78 year old male, both known for having multiple asymptomatic gallstones discovered on a previous abdominal CT-scan (figures 1, 2). Both described a history of upper abdominal pain, distension and vomiting with gradual evolution over 1 week for the female and 3 for the male. They present maximal abdominal pain at the right upper quadrant but the entire abdomen is distended and painful. The two had a scanner which showed signs of gallstone ileus. The female had 2 stones more than 2.5cm in diameter in the distal jejunum (figures 3, 4). The male had 1 stone at the jéjuno-iléal junction and another in the stomach (figures 5, 6).

Figure 1
Figure 2
Figure 3
Figure 4.1
Figure 4.2
Figure 5
Figure 6

Results

An emergent laparoscopy was planned for the female and a laparotomy was chosen for the male. The female had a single enterolithotomy with extraction of both calculi by a limited transverse infra-umbilical incision after a laparoscopic spotting of the obstruction site. The male had a laparotomy and a segmental resection was performed at the jejuno-ileal junction because of segmental necrosis. An anterior gastrotomy did not permit the extraction of the 3cm diameter stone. It was subsequently endoscopically removed (figure 7). No other stones were palpated throughout the bowel. The outcome was satisfactory in both cases, however with an extended intensive care unit stay for the male.

Figure 7

Conclusion

Laparoscopic approach can be safe gallstone ileus. The entire bowel should be palpated to rule out further stones. Surgical literature does not help define a management strategy, though there is a consensus that Entherolythotomy alone is the safest option in frail elderly patients.