What is the management of gallstone ileus?

Management of Gallstone Ileus

Enterolithotomy alone is the preferred surgical approach for gallstone ileus, particularly in elderly patients with comorbidities, as it resolves the intestinal obstruction with lower morbidity and mortality compared to more extensive procedures. 1

Diagnosis

• Clinical Presentation:

  • Intestinal obstruction symptoms (abdominal pain, vomiting, distention)
  • Often in elderly patients with history of gallstone disease
  • Delayed presentation with non-specific symptoms

• Imaging:

  • CT scan with IV contrast is the most definitive diagnostic tool
  • Classic Rigler's triad: pneumobilia, small bowel obstruction, ectopic gallstone 2
  • Ultrasound may be performed initially but is often inconclusive 3

Surgical Management Options

1. Enterolithotomy Alone (Preferred First-Line Approach)

• Simple removal of the obstructing gallstone through enterotomy
• Advantages:
  • Shorter operative time
  • Lower postoperative morbidity and mortality
  • Particularly beneficial for elderly patients with multiple comorbidities 1
• Postoperative stay averages 9.4 days 1

2. One-Stage Procedure

• Enterolithotomy + cholecystectomy + fistula repair in same operation
• Consider only in:
  • Younger, stable patients
  • Minimal comorbidities
  • Good surgical candidates
• Disadvantages:
  • Longer operative time
  • Higher morbidity and mortality
  • Longer hospital stay (average 18.6 days) 1

3. Two-Stage Procedure

• Initial enterolithotomy followed by delayed cholecystectomy and fistula repair
• Appropriate for:
  • Patients who recover well from initial surgery
  • Those with persistent biliary symptoms after enterolithotomy

Minimally Invasive Approaches

• Laparoscopic enterolithotomy:

  • Feasible in selected patients
  • Associated with faster recovery and shorter hospital stay (as short as 3 days) 4
  • Requires advanced laparoscopic skills

• Endoscopic removal:

  • Possible when stone is located in accessible portions of the colon 5, 3
  • Avoids need for general anesthesia in high-risk patients

Special Considerations

• Stone location:

  • Most commonly found in terminal ileum (site of narrowest lumen)
  • Can also be found in jejunum, duodenum, or colon

• Fistula type:

  • Cholecystoduodenal fistula is most common
  • Cholecystocolonic fistula is rare but possible 5

• High-risk patients:

  • For patients unfit for general anesthesia, consider:
    • Endoscopic removal if accessible
    • Trephine loop colostomy under local anesthesia for colonic stones 5

Postoperative Care

• Monitor for:

  • Signs of ongoing infection
  • Recurrent obstruction
  • Wound complications

• Recurrence of gallstone ileus is rare after successful enterolithotomy 1

Pitfalls to Avoid

• Delaying diagnosis due to non-specific symptoms
• Performing extensive surgery (one-stage procedure) in high-risk elderly patients
• Missing additional stones during surgery (multiple stones present in some cases)
• Overlooking the need for individualized approach based on patient comorbidities and stone location

The management of gallstone ileus requires careful consideration of patient factors and surgical expertise. While enterolithotomy alone is generally preferred in elderly patients with comorbidities, minimally invasive approaches should be considered when feasible to improve postoperative outcomes.