What is the management approach for an elderly patient with a history of gallstones or biliary disease suspected of having gallstone ileus?

Management of Gallstone Ileus in Elderly Patients

Immediate Surgical Intervention Required

Gallstone ileus is a surgical emergency requiring urgent laparotomy with enterolithotomy as the primary life-saving intervention, with the decision for concurrent biliary surgery (cholecystectomy and fistula repair) determined by patient stability and surgical risk factors. 1, 2

Diagnostic Approach

Clinical Presentation

• Elderly patients (mean age 74-77 years) presenting with mechanical bowel obstruction symptoms: abdominal pain, vomiting, and distension 1, 2, 3
• Female predominance (4.5:1 ratio) with symptom duration typically 2-6 days before presentation 2, 3
• High-risk population: 86.4% of patients are ASA class III or IV 2

Imaging Strategy

• CT scan is the diagnostic modality of choice, achieving preoperative diagnosis in 77% of cases by identifying the classic triad: pneumobilia, bowel obstruction, and ectopic stone 1, 2
• Plain abdominal radiography may show calcified stones but has limited sensitivity 1
• Ultrasound has limited utility for diagnosing gallstone ileus specifically, though it remains useful for initial gallstone disease evaluation 4

Surgical Management Algorithm

Primary Intervention: Enterolithotomy

All patients require urgent laparotomy with enterolithotomy to relieve the mechanical obstruction 2, 3, 5

• Stone location: terminal ileum (77% of cases) or jejunum (23%), with mean stone size 3.6 cm 2
• Critical intraoperative step: Thoroughly palpate the entire small bowel proximally and distally to identify additional migrating stones, as recurrent obstruction can occur within days if missed 6

Decision Framework for Concurrent Biliary Surgery

One-Stage Procedure (Enterolithotomy + Cholecystectomy + Fistula Repair):

• Reserved for hemodynamically stable patients with good cardiorespiratory reserve 2, 3, 5
• Appropriate when there are absolute indications for biliary surgery at presentation (e.g., gangrenous gallbladder, ongoing cholecystitis) 2, 5
• Mortality risk: 11% with morbidity 37.5% 5

Enterolithotomy Alone:

• Preferred approach for the majority of elderly patients given high ASA classification and significant comorbidities 2, 3, 5
• Postoperative cholangitis risk is low (approximately 5% over 3-4 years follow-up) 2, 3
• Allows for interval cholecystectomy in select cases after patient optimization 5

Critical Pitfalls and Management Considerations

Recurrence Risk

• Recurrent gallstone ileus is rare but can occur within days to weeks of initial surgery 6
• Maintain high index of suspicion if obstruction symptoms recur postoperatively—repeat CT imaging immediately 6
• Meticulous intraoperative examination for multiple stones is essential to prevent recurrence 6

Mortality and Morbidity

• Overall mortality: 11-23% in elderly patients, primarily from cardiovascular complications and sepsis 2, 5
• Postoperative complications include wound dehiscence, infection, and obstructive jaundice 5
• Mean hospital stay: 14 days for enterolithotomy alone versus 19 days for one-stage procedures 3

Timing Considerations

• Do not delay surgery for extensive preoperative optimization—mean diagnostic delay of 3.5 days is already associated with increased morbidity 2
• The mechanical obstruction itself drives mortality risk, making prompt surgical relief paramount 1, 2

Postoperative Management

• Close monitoring for recurrent obstruction symptoms in the immediate postoperative period 6
• Long-term follow-up shows excellent outcomes with enterolithotomy alone—no mandatory requirement for subsequent biliary surgery in asymptomatic patients 2, 3
• If cholangitis develops during follow-up (rare), it can typically be managed medically without urgent surgical intervention 2