Biliary Tract: Gallstone Ileus

Basics

• Gallstone Impaction in Bowel Causing SBO
  • Misnomer – Not a True Ileus
• Cause: Cholecystoenteric Fistula Between Gallbladder & GI Tract
• Most Common Site of Fistula: Duodenum (2^nd Portion)
• Most Common Site of Impaction: Ileum
• Bouveret’s Syndrome – Gastric Outlet Obstruction from Gallstone Impaction at Pylorus

Diagnosis

• Dx: CT
• Rigler’s Triad on Plain Radiograph:
  • Pneumobilia
  • Small Bowel Obstruction (SBO)
  • Large Calcified Stone in Bowel Lumen

Treatment

• Tx: Enterolithotomy, Cholecystectomy & Fistula Closure
  • Enterolithotomy – Extract Stone by a Proximal Enterotomy
    • Open Longitudinally & Close Transversely
  • Cholecystectomy & Fistula Closure Can Be Done at Index Procedure or Delayed
• Timing:
  • Stable & Low-Risk (ASA Class I-II): One-Stage Procedure
    • *Controversial and Some Authors Recommend Enterolithotomy Alone (Two-Stage Procedure is the “Safe Answer”)
  • Unstable or High-Risk (ASA Class ≥ III): Two-Stage Procedure
    • Stage 1 – Enterolithotomy
    • Stage 2 – Cholecystectomy & Fistula Closure When Stable/Optimized
• Many (25%) Harbor Multiple Stones in the GI Tract – Requires Careful Inspection