Gallstone ileus K56.3

Erasmus Bartholin was the first to describe gallstone ileus in 1654 (Turner 2022).

In 1896, Leon Bouveret was the first to describe a rare form of gallstone ileus, Bouveret's syndrome, which was later named after him (Höink 2016).

Gallstone ileus is the occurrence of a complication of cholelithiasis (Turner 2022) in which there is leakage of the gallstone from the gallbladder or bile ducts into the intestine via a cholecysto-enteric fistula (Kasper 2015). Once the stone becomes lodged in an ileal loop, ileus occurs (Alaez- Chillaron 2017).

One differentiates between

- symptomatic and

- clinically silent biliary-enteric fistulas (Kasper 2015)

- Bouveret syndrome:

This is a rare form of gallstone ileus in which there is intraluminal obstruction of the bulbus duodeni due to a gallstone (Höink 2016). This causes obstruction of the gastric outlet (Inukai 2019). This mainly affects older women (Höink 2016).

Gallstone ileus is one of the rarest forms of all mechanical bowel obstructions (Turner 2022).

It is found as a cause in 4% of all patients with ileus, but the number increases to 25% in those >65 years of age (Ploneda- Valencia 2017).

At the same time, gallstone ileus is the most common cause of non-strangulating bowel obstruction. It occurs in 0.3-0.5% of patients with cholelithiasis (Turner 2022). The recurrence rate is 5 - 8% (Inukai 2019).

Fistulas form between the gallbladder and gastrointestinal tract in less than 1% of patients with gallstones (Gutt 2018). Clinically silent biliary-enteric fistulas are found in approximately 5% of all patients undergoing cholecystectomy (Kasper 2015).

Women are more commonly affected by gallstone ileus than men (3.5: 1), with an additional increase in incidence with age (Turner 2022).

Gallstone ileus results from perforation of a large gallstone through a biliary-enteric fistula into the intestine, which can lead to obstruction of the ileum (Herold 2022).

Risk factors include:

- longstanding cholelithiasis

- Gallstones greater than 2 cm in diameter (Turner 2022).

Several mechanisms play a role in the development of gallstone ileus:

- 1. adhesions

Inflammatory changes in the gallbladder can cause adhesions to form between the gallbladder and the adjacent gastrointestinal tract (Turner 2022).

Thus, fistula formation of the gallbladder wall into an organ adherent to the gallbladder wall may occur. Most commonly, fistulas are found in descending order in the duodenum (approximately 60% [Turner 2022]), hepatic flexure of the colon, stomach, jejunum, abdominal wall, or renal pelvis (Kasper 2015).

- 2. pressure necrosis

Large stones can cause pressure necrosis with signs of inflammation between the gallbladder and gastrointestinal tract (Turner 2022).

Stones > 2.5 cm in particular are thought to promote fistula formation by gradual erosion (Kasper 2015).

3. buried gallstones

Gallstones spilled during laparoscopic surgery can lead to an intra-abdominal abscess. This can ulcerate the bowel wall, allowing the stone to enter the intestinal lumen (Turner 2022).

The degree of obstruction depends on the position of the gallstone in the gastrointestinal tract. At times, the gallstone may even pass the rectum without notice (Turner 2022).

In most cases, gallstone ileus is localized in the region of the ileocecal valve (Kasper 2015).

Symptoms of cholecystitis can be elicited from the anamnesis of most patients (Kasper 2015).

In the acute stage of gallstone ileus, the triad of the following symptoms is typical:

- Aerobilia (radiologically detectable air in the gallbladder or bile ducts).

- small bowel ileus

- Stone shadow (Herold 2022).

Patients often complain of intermittent non-specific symptoms such as:

- intermittent abdominal pain.

The intensity of the pain usually does not correlate with underlying anatomic conditions (Turner 2022). This episodic subacute ileus is also referred to as "tumbling obstruction" (Shekhda 2021).

- Bloating

- Nausea

- Vomiting

- constipation

- Icterus in approximately 33% (Turner 2022).

The diagnosis of gallstone ileus is often delayed due to the unspecific symptoms and the so-called "tumbling phenomenon", i.e. the stone tumbling through the gastrointestinal tract during the examination. As a rule, it takes 3 - 8 days from the onset of symptoms until the diagnosis is made, and most frequently a gallstone is found as the cause of an ileus of unclear origin only during surgery (Turner 2022).

Physical examination

This is often nonspecific. Sometimes tense abdominal wall and/or auscultatory high bowel sounds are seen (Turner 2022).

Abdominal X-ray

In the simple abdominal overview radiograph, asymptomatic cholecysto- enteritic fistulas can sometimes already be detected by detection of gases in the bile duct (Kasper 2015).

Typically, the so-called Rigler triad presents with:

- partial or complete intestinal obstruction

- pneumobilia or visualization of contrast in the bile ducts (Turner 2022)

- ectopic gallstone (however, sensitivity is only 33% for the latter [Inukai 2019]).

Abdominal sonography

This can be used to visualize trapped gallstones, but the exact location can often be difficult to determine due to intestinal gas (Turner 2022).

Endoscopy

Endoscopy of the upper gastrointestinal tract or barium contrast examination can also detect fistulas (Kasper 2015).

Computed tomography

The sensitivity of CT is 93%. This shows thickening of the gallbladder wall, pneumobilia, ileus, and obstructing gallstones (Turner 2022).

The sensitivity of CT to ectopic gallstones is 81% (Inukai 2019).

CT may demonstrate an additional sign of gallstone ileus: there are two air-fluid levels in the right upper quadrant. These correspond to the duodenum and gallbladder (Turner 2022).

MRCP

Magnetic resonance cholangiopancreatography should be performed as an additional diagnostic procedure if CT has not resolved all questions (Turner 2022).

Liver enzymes increase in approximately one-third of affected individuals (Turner 2022).

- choledocholithiasis

- cholecystitis

- acute pancreatitis

- ulcers of the gastrointestinal tract

- Malignancy of the choledochal duct (Turner 2022).

- Infection

- Pancreatitis (Turner 2022)

- Ileus

Intestinal obstruction is found in the ileum in approximately 60% of patients with gallstone ileus (Kasper 2015).

- Acute renal failure

- urinary tract infections

- Biliary fistula

- wound dehiscence

- sepsis

- intraabdominal abscess

- anastomotic insufficiency (Turner 2022)

Surgical options for gallstone ileus are:

- simple entero-stonectomy

- enterolithotomy with cholecystectomy and closure of the fistula as a one-stage procedure

- Enterolithotomy and later performed cholecystectomy as a so-called two-stage procedure (Turner 2022).

Mortality is higher for single-stage surgery at 16.9% (Turner 2022) than for two-stage surgery (Turner 2022). Inukai (2019) recommends two-stage surgery for impaction at the level of the ileum and one-stage surgery for impaction at all other sites of the gastrointestinal tract.

Since the symptoms are often intermittent and the cause of the disease can sometimes only be determined with a delay, gallstone ileus is still associated with a relatively high mortality rate of 12-27% (Turner 2022). Thus, the mortality of gallstone ileus is 5-10 times higher than that of mechanical ileus of other causes (Shekhda 2021).

In patients operated on second time around, Kaneda et al. (2007) found natural closure of the cholecysto-enteric fistula intraoperatively in 61.5% of affected patients (Inukai 2019).

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