What is the best management approach for an elderly patient with a history of gallstones (cholelithiasis) presenting with intestinal obstruction (IO) and an x-ray showing a stone in the terminal ileum?

Management of Gallstone Ileus in Elderly Patients

Enterolithotomy (option A) is the preferred management approach for an elderly patient with gallstone ileus presenting with intestinal obstruction and x-ray showing a stone in the terminal ileum.

Understanding Gallstone Ileus

Gallstone ileus is a rare complication of cholelithiasis that causes mechanical intestinal obstruction due to impaction of one or more large gallstones within the gastrointestinal tract. It typically occurs through a cholecystoduodenal fistula that allows gallstones to enter the intestinal tract.

Surgical Management Options

Three main surgical approaches exist for gallstone ileus:

1. Enterolithotomy alone - Simple removal of the obstructing stone
2. One-stage procedure - Enterolithotomy + cholecystectomy + fistula repair
3. Stone crushing - Manual fragmentation of the stone

Evidence-Based Recommendation

Why Enterolithotomy is Preferred:

• Lower mortality risk: Enterolithotomy alone carries significantly lower morbidity and mortality compared to the one-stage procedure in elderly patients 1
• Shorter operative time: Critical for high-risk elderly patients who may have multiple comorbidities
• Addresses the immediate life-threatening condition: Relieves the obstruction quickly without subjecting the patient to prolonged anesthesia

Against One-Stage Procedure (Option B):

While a one-stage procedure (enterolithotomy plus cholecystectomy) may be appropriate for younger, stable patients 2, it carries significantly higher risks in elderly patients:

• Higher morbidity (20-40%) and mortality (1.3-4%) rates 3
• Prolonged operative time in potentially unstable patients
• Increased risk of postoperative complications in elderly patients

Against Stone Crushing (Option C):

Manual crushing of the stone without removal:

• Risks incomplete resolution of the obstruction
• May cause mucosal injury to the bowel
• Does not address the stone that caused the obstruction

Clinical Decision Algorithm

1. Confirm diagnosis:

   • X-ray showing stone in terminal ileum (Rigler's triad: small bowel obstruction, pneumobilia, and ectopic gallstone)
   • Clinical signs of intestinal obstruction

2. Assess patient stability:

   • If unstable: Fluid resuscitation, antibiotics, and prompt enterolithotomy
   • If stable: Consider patient's overall condition and comorbidities

3. Surgical approach based on patient factors:

   • For elderly patients: Enterolithotomy alone (preferred)
   • For younger, stable patients with good cardiorespiratory reserve: Consider one-stage procedure

Postoperative Considerations

• Monitor for wound complications, as wound dehiscence and infection are common complications 4, 1
• Follow-up at 7-10 days for wound evaluation 5
• Consider elective cholecystectomy later only if the patient develops recurrent biliary symptoms

Pitfalls to Avoid

• Don't underestimate the risk: Gallstone ileus carries high morbidity and mortality in elderly patients
• Don't automatically perform the one-stage procedure: Reserve this for carefully selected stable patients
• Don't miss additional stones: Complete examination of the bowel is essential to prevent recurrent obstruction 6
• Don't crush stones without removal: This approach risks incomplete resolution and bowel injury

In conclusion, enterolithotomy alone represents the safest and most effective approach for elderly patients with gallstone ileus, focusing on resolving the immediate life-threatening condition while minimizing surgical risk.