Resolution of gallstone ileus with spontaneous evacuation of gallstone
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Gallstone ileus (GSI) is a rare cause of small bowel obstruction (SBO). Even more extraordinary is the spontaneous evacuation of a gallstone, which has caused SBO. A 69-year-old gentleman presented with symptoms and signs of SBO. His plain abdominal X-ray revealed dilated loops of the small bowel and opacity in the region of the terminal ileum consistent with a diagnosis of GSI. Because of severe cardiorespiratory co-morbidities, the patient was treated conservatively and improved within 24 h. A CT scan revealed that the stone had passed into the rectum and was spontaneously evacuated. If the gallstone is <2.5 cm on CT scan, spontaneous evacuation is a real possibility and initial conservative treatment in a high-risk surgical patient is a consideration.
KeywordsGallstones Rectal gallstone Small bowel obstruction Cholecystoenteric fistula Gallstone ileus Spontaneous evacuation Human
Gallstone ileus (GSI) accounts for about 1–3% of mechanical obstruction of the small bowel, but for 25% of all small bowel obstruction (SBO) in patients older than 65 years . It is caused by intra-luminal impaction of one or more gallstones, which enter the small bowel usually via a cholecystoenteric fistula. Spontaneous passage of a stone that has caused SBO is extremely rare. Surgery is the treatment of choice, either in the form of enterolithotomy alone to relieve obstruction with biliary tract surgery at a later date (two-stage procedure) or enterolithotomy plus fistula repair and cholecystectomy (one-stage procedure) . We describe a case of SBO secondary to gallstone in a 69-year-old male with multiple medical co-morbidities (making him high risk for surgery), which was treated conservatively with subsequent resolution of symptoms due to spontaneous evacuation of the gallstone.
The term gallstone ileus, first described by Bartolin in 1654, is really a misnomer as impaction of one or more gallstones in the lumen of the bowel leads to a true mechanical obstruction. It is a rare disease and only accounts for about 1–3% of mechanical ileus of the small bowel, but for 25% of all SBOs in patients older than 65 years .
GSI is frequently preceded by an episode of acute cholecystitis. The resulting inflammation and adhesions facilitate the erosion of the offending gallstone through the gall bladder wall forming a cholecystoenteric fistula and allowing the passage of the gallstone . The site of impaction can be anywhere in the gastrointestinal tract. The terminal ileum is the most common location because of the narrow lumen and potentially less active peristalsis. Gallstone impaction in the large bowel has been described but is a much rarer condition probably because most gallstones that are small enough to pass through the ileocaecal valve readily pass through the rectum. In cases of gallstone obstruction of the large bowel, the stone almost always impacts at the level of the sigmoid colon, usually due to a pathologic narrowing at that point (e.g. secondary to a history of diverticulitis) .
Once a gallstone becomes impacted within the intestinal lumen, surgery is the treatment of choice. The appropriate surgical intervention in the emergency setting for GSI is controversial. This relates to the need for definitive biliary tract surgery after relief of obstruction [2, 5]. The choices are enterolithotomy alone or enterolithotomy in combination with cholecystectomy, fistula closure and common bile duct exploration, if indicated . Enterolithotomy alone can predispose to complications related to persistence of the biliary enteric fistula. This includes the possibility of recurrent GSI , cholecystitis and cholangitis . On the other hand, definitive cholecystectomy and fistula closure is related to prolonged operating time with a risk of enteric or biliary leakage and a higher mortality rate . Furthermore, cholecystectomy in patients with GSI is usually technically demanding due to the multiple episodes of cholecystitis, leading to the formation of dense adhesions between the gallbladder and the adjacent hollow viscera (mainly the duodenum and, more rarely, the colon). Opinions and data regarding these two surgical strategies are divided and there are no randomised, controlled studies to answer these issues.
What is clear however, is that surgical intervention for GSI carries a high peri-operative mortality rate (up to 50%) [1, 2]. The reason for this is that a high percentage of these patients are elderly and have multiple co-morbidities and also this condition is notoriously difficult to diagnose, often leading to a delay in treatment with deterioration of the pre-operative status [2, 9, 10]. Alternate procedures such as extracorporeal shock wave lithotripsy and electrohydraulic or mechanical lithotripsy have been suggested, but this depends on the site of the obstruction. If the stone moves into the large bowel, the use of enemas or colonoscopic removal of the stone should be attempted, but this procedure may not always be possible .
Once a gallstone has become impacted within the small bowel and causes obstruction, a spontaneous evacuation is extremely rare. The smaller an impacted stone becomes, the more easily it is evacuated. Previous reports have suggested that a gallstone must be at least 2.5 cm in diameter to cause an intestinal obstruction in the normal bowel . In our case, we estimated the size of the impacted stone to be 2.2 cm on CT scan (Fig. 2). The unusual impaction of a stone less than 2.5 cm in our case may be due to spasm, bowel angulation or the prior abdominal surgery (appendectomy), which could have played a pathological role in the development of the obstruction.
In our case, we opted for conservative initial treatment due to concomitant diseases and the high risk of surgery. Although we still advocate surgery as the treatment of choice for GSI because spontaneous evacuation is a rarity, there may be a case for a conservative initial approach in patients at high risk for surgery particularly if the obstructing gallstone is estimated to be smaller than 2.5 cm based on CT findings.
Resolution of GSI secondary to spontaneous evacuation of the gallstones is a rarity. However, if the gallstone is <2.5 cm on CT scan, spontaneous evacuation is a real possibility and initial conservative treatment for 48 h especially in a high-risk surgical patient is a real consideration and may lead to a successful outcome.
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