What is the recommended approach for the endoscopic management of gallstone ileus in an elderly patient with potential comorbidities?

Endoscopic Management of Gallstone Ileus

Surgery remains the definitive treatment for gallstone ileus, but endoscopic removal can be attempted in highly selected cases when the stone is accessible and the patient is at prohibitive surgical risk, though success rates are variable and most cases ultimately require operative intervention.

Understanding Gallstone Ileus

Gallstone ileus is a rare mechanical bowel obstruction (1-4% of all cases) that predominantly affects elderly patients, particularly women over 70 years, with mortality rates that can be substantial due to delayed diagnosis and patient comorbidities 1, 2. The condition results from a cholecystoenteric fistula allowing large gallstones (typically 2.5-4 cm) to enter the gastrointestinal tract, most commonly impacting in the terminal ileum 1, 2.

Role of Endoscopy: Limited but Evolving

When Endoscopic Removal May Be Considered

Endoscopic extraction should only be attempted when:

• The stone is located in accessible portions of the bowel (duodenum, proximal jejunum, or colon) 3, 1
• The patient has prohibitive surgical risk (ASA III/IV, severe comorbidities, advanced frailty) 4
• Appropriate expertise and equipment are immediately available 3, 5

Endoscopic Techniques Reported

For colonic gallstone ileus:

• Electrohydraulic lithotripsy can fragment large impacted stones in the sigmoid colon by excavating a cavity in the stone, followed by pneumatic balloon dilatation to fracture fragments for removal 3
• This approach requires specialized equipment and expertise, with success reported in isolated cases 3

For small bowel gallstone ileus:

• Single-balloon or double-balloon enteroscopy enables access to ileal stones that conventional endoscopy cannot reach 5
• Successful peroral single-balloon enteroscopic removal has been documented in an 81-year-old patient with ileal impaction 5

Critical Limitations of Endoscopic Approach

The endoscopic approach frequently fails and should not delay definitive surgical management:

• Attempted endoscopic removal failed in reported cases, necessitating emergent laparotomy 1
• Variable outcomes make endoscopy unreliable as primary treatment 6
• Most stones are impacted in the terminal ileum (90% of cases), beyond reach of conventional endoscopy 2
• Stone size (2.5-4 cm) often precludes intact removal 2

Surgical Management Remains Standard of Care

Primary Surgical Approach

Enterolithotomy is the preferred definitive treatment:

• Open or laparoscopic enterolithotomy should be performed based on surgeon expertise 2
• Laparoscopic approach when feasible results in shorter hospital stay (5 days vs 10 days for open) 2
• One-stage procedure (enterolithotomy, cholecystectomy, and fistula repair) can be performed in stable patients 1

Special Considerations in Elderly Patients

Age alone does not contraindicate surgery, but comprehensive risk assessment is essential:

• Evaluate frailty using validated scores, as frail patients have 1.8-2.3 fold increased morbidity/mortality risk 7
• Consider mortality rates for both conservative and surgical options 4
• Assess age-related life expectancy and performance status 4

For patients deemed unfit for immediate surgery:

• Initial conservative management with bowel rest and supportive care may allow stone passage in rare cases 2
• However, 80% (8/10 patients) ultimately required surgical intervention 2

Clinical Pitfalls to Avoid

Delayed diagnosis significantly increases mortality:

• Maintain high index of suspicion in elderly patients with bowel obstruction and history of gallstones (70% have prior gallstone history) 2
• CT imaging is diagnostic, showing pneumobilia, bowel obstruction, and ectopic stone 1
• Plain films may show calcified stones but are less sensitive 1

Do not pursue prolonged endoscopic attempts:

• If initial endoscopic removal fails, proceed immediately to surgery rather than repeated attempts 1, 6
• Endoscopy should not delay surgical consultation in unstable patients 6

Laboratory derangements are common:

• 50% have abnormal liver function tests and acute kidney injury 2
• 60% have elevated inflammatory markers 2
• These findings reflect the severity of illness and need for urgent intervention 2

Practical Algorithm

1. Confirm diagnosis with CT showing pneumobilia, obstruction, and ectopic stone 1
2. Assess surgical candidacy using frailty scores and comorbidity evaluation 4, 7
3. If stone is in colon or proximal bowel AND patient has prohibitive surgical risk: Consider endoscopic removal with electrohydraulic lithotripsy or balloon enteroscopy 3, 5
4. If endoscopy fails or stone is in distal ileum: Proceed directly to enterolithotomy (laparoscopic preferred if expertise available) 2
5. In stable patients: Consider one-stage procedure including cholecystectomy and fistula repair 1
6. In unstable/frail patients: Perform enterolithotomy alone, defer cholecystectomy 4