Acute abdomen - gallstone ileus

Laboratory tests showed: elevated amount of white blood cells : (14, 2 109 /l) and higher haematocrit (0,5) because of dehydratation. Patient was without anaemia. C- reactive protein (57 mg/ml), total bilirubin (42 mg/dl) and amylase (5,2µkat/) was elevated. Patient had slightly elevated hepatic enzymes in serum.

Plain abdominal X-ray showed typical sight of ileus- string-of-beads sign: small pockets of gas within a fluid-filled small bowel and pneumobilia (presence of air in biliary tree), too (Figure 1). The presence of stone was not visible.

Ultrasonography revealed two signs from three of Rigled triad, pneumobilia in biliary tree (Figure 2), and extremely dilatated loops of jejunum with excessive fluid in jejunum and stomach, too.

Gastroscopic examination was without pathologic finding, even stomach peristalsis was visible.

Patient was sent to MRCP (Magnetic Resonance CholangioPancreatography- uses a powerful magnetic field, radio waves to evaluate the liver, gallbladder, bile ducts, pancreas and pancreatic duct for disease. It is noninvasive and does not use ionizing radiation). Examination didn´t show fistula as we expected, there was visible only cholecystitis, fluid around gallbladder and suspect perforation of gallbladder. Biliary tree was without presence of stones and there was no dilatation (this is indirect sign of mechanical obstruction of biliary tree (Figure 3).

Based on radiological and clinical assessments and general status of patient we decided to undertake a surgical intervention. An exploratory upper medial laparotomy was performed: revealing a 4-cm gallstone impacted just 60 cm caudal to the Treitz ligament by palpation. We couldn´t perform an enterolithotomy because of oedema of jejunum. After resection of 15 cm of bowel , the both ends of jejunum was sutured in two layers (Figure 4, 5).

Pathologist described in samples phlegmonous inflammation of jejunal wall. Because of a lot of adhesions between gallbladder, duodenum and stomach in subhepatal space, we didn´t repair fistula between gallbladder and duodenum.

Patient was discharged after 19 days of hospital stay.

Gallstone ileus is a rare mechanical intestinal obstruction caused by the passage of gallstones into the gastrointestinal lumen especially in elderly people. Gallbladder stones are frequently asymptomatic, mostly patients don´t know about presence of stones in gallbladder. The pathogenesis of gallstone ileus involves adhesions forming between the inflamed gallbladder and an adjacent part of the gastrointestinal tract (stomach, duodenum). Subsequently, large stones within the gallbladder cause pressure necrosis, resulting in formation of a cholecyst–enteric fistula, which allows gallstones direct access to the gut (cholecystoduodenal, cholecysto-colonic, cholecysto-gastric fistula). Gallstone causes an intestinal obstruction usually in ileum, because of it´s smallest diameter.

The clinical signs and symptoms of gallstone ileus are usually non-specific, contributing to a delay in diagnosis. However, the common symptoms of intestinal obstruction, such as abdominal pain, nausea, vomiting and constipation predominate, usually intermittently as the stone travels through the bowel. Bouveret's syndrome is a rare cause of gastric outlet obstruction. It is characterized by the passage of a large gall bladder stone through a bilio-duodenal fistula, which becomes lodged in the duodenum causing duodenal obstruction. and can cause duodenal bleeding. CT or MRCP is the most suitable imaging method for diagnostic.

Rigler triad helps to diagnose biliary ileus : it consists of three findings: pneumobilia-presence o fair in biliary tree, small bowel obstruction and ectopic gallstone, usually in the right iliac fossa (not visible on X ray except the stones, which contain salts of calcium).

Gastroscopy can be helpful in the case of duodenal obstruction. Colonoscopy and irigography is indicated in the case of low ileus – suspection of Bauhin valve obstruction or ileus of large intestine.

Treatment remains controversial:

1. Enterolithotomy and extraction of the stone will resolve the intestinal obstruction, but leave the patient at risk of further obstruction if there are residual stones within the gallbladder, persistent symptoms from an inflamed gallbladder and a possible increased risk of developing gallbladder cancer.
2. Enterolithotomy, cholecystectomy and fistula repair as a one-stage procedure, is more risky for elderly patients and bring higher morbidity and mortality in postoperative period.