What is the treatment for gallstone ileus?

Gallstone Ileus Treatment

Gallstone ileus requires urgent surgical intervention with enterolithotomy as the primary life-saving procedure, with one-stage cholecystectomy and fistula repair added only if the patient's condition permits and anatomy is favorable.

Immediate Surgical Management

Enterolithotomy alone is the mainstay of treatment and should be performed urgently to relieve bowel obstruction. 1, 2 This approach prioritizes mortality reduction in what is typically an elderly, high-risk population with significant comorbidities. 3, 1

One-Stage vs. Staged Approach

• For stable patients with favorable anatomy: Perform one-stage procedure including enterolithotomy, cholecystectomy, and fistula repair to prevent future biliary complications 2
• For unstable or high-risk patients: Enterolithotomy alone should be performed, reserving definitive biliary surgery for elective intervention if needed 3, 1, 2
• Critical caveat: Severe inflammatory adhesions around the fistula site may preclude safe manipulation, making enterolithotomy alone the prudent choice even in otherwise stable patients 3

Clinical Context and Mortality Risk

Gallstone ileus carries high morbidity (37.5%) and mortality (11%) rates, predominantly affecting elderly patients over 65 years who account for 25% of all bowel obstructions in this age group. 4, 2 The condition results from chronic cholecystitis causing bilioenteric fistula formation, most commonly cholecystoduodenal (89%) or cholecystocolonic (11%). 2

Diagnostic Confirmation

• CT imaging is diagnostic, revealing Rigler's triad: pneumobilia, bowel obstruction, and ectopic gallstone 4
• The impacted stone is typically found in the jejunum or ileum 4, 3

Surgical Decision Algorithm

Primary goal: Save the patient's life by relieving obstruction. 1

1. Assess patient stability: Age, comorbidities, hemodynamic status
2. Evaluate intraoperative anatomy: Degree of inflammation, adhesions, fistula accessibility
3. If unstable OR severe inflammation: Enterolithotomy alone 3, 1
4. If stable AND favorable anatomy: One-stage procedure with cholecystectomy and fistula repair 2
5. Thoroughly examine entire bowel: Check for additional migrating stones to prevent recurrence 5

Important Pitfalls

• Delayed intervention significantly increases mortality - this is a surgical emergency requiring prompt operative management 3
• Attempting complex biliary reconstruction in unstable patients is contraindicated and may lead to catastrophic complications including septic shock and multiple organ failure 4
• Recurrent gallstone ileus can occur within weeks if additional stones are missed during initial surgery 5
• Non-surgical approaches (endoscopic lithotripsy) have failed to provide adequate treatment and should not delay definitive surgical intervention 4

Postoperative Considerations

Patients who undergo enterolithotomy alone may require elective cholecystectomy and fistula repair later if symptoms recur, though many remain asymptomatic on long-term follow-up. 2 Future biliary complications should be addressed electively under more favorable circumstances if they occur. 1