How should I manage a 70‑year‑old woman with asymptomatic gallbladder hydrops who now presents with an ileus?

Management of Ileus in a 70-Year-Old Woman with Asymptomatic Gallbladder Hydrops

In this clinical scenario, you should focus on treating the ileus conservatively while holding oral lactulose if the patient has hepatic encephalopathy, and simultaneously investigate whether the ileus is caused by a rare complication of gallstone disease—specifically gallstone ileus—which would require urgent surgical intervention. 1, 2

Immediate Diagnostic Priorities

Rule Out Gallstone Ileus First

• Gallstone ileus is a rare but life-threatening complication that occurs when a gallstone erodes through the gallbladder wall, creates a cholecystoenteric fistula, and obstructs the small bowel. 2, 3
• This condition accounts for 1-4% of all mechanical intestinal obstructions and predominantly affects elderly women—exactly your patient's demographic. 3, 4
• The mortality rate is high if diagnosis is delayed, making early recognition critical. 2, 3

Obtain Abdominal CT Immediately

• CT imaging is essential to differentiate simple ileus from gallstone ileus by identifying the classic triad: pneumobilia, bowel obstruction, and an ectopic stone within the bowel lumen. 3
• Plain abdominal films may show calcified stones in unusual locations or signs of bowel obstruction, but CT is far more sensitive for diagnosis. 3
• The presence of gallbladder hydrops increases suspicion for cholecystoenteric fistula formation, as chronic distention and inflammation predispose to erosion. 2, 5

If Gallstone Ileus Is Confirmed

Surgical Management Is Mandatory

• Emergent laparotomy with enterolithotomy (removal of the obstructing stone) is the standard of care and should be performed urgently. 3, 4
• Perform enterolithotomy alone as the initial procedure; do NOT attempt one-stage cholecystectomy and fistula repair in this elderly, high-risk patient with acute obstruction. 4
• One-stage procedures (enterolithotomy plus cholecystectomy plus fistula repair) carry significantly higher mortality in elderly patients with comorbidities. 4
• Cholecystectomy and fistula repair can be deferred and performed electively later only if recurrent biliary symptoms develop—which occurs in a minority of cases. 4

Pitfall to Avoid

• Do NOT delay surgery attempting endoscopic stone extraction; this approach has a high failure rate and leads to unnecessary delays in definitive treatment. 3

If Simple (Non-Obstructive) Ileus Is Confirmed

Conservative Management of Ileus

• Hold all oral medications and enteral feeding, including lactulose if the patient is receiving it for hepatic encephalopathy. 1
• Nasogastric decompression may be needed if the patient has significant abdominal distention or vomiting. 1
• Correct electrolyte abnormalities (particularly hypokalemia and hypomagnesemia) and ensure adequate hydration, as these are common precipitants of ileus. 1

If Hepatic Encephalopathy Is Present

• In the setting of ileus with Grade 3 or 4 hepatic encephalopathy, administer lactulose enemas (300 mL lactulose in 700 mL water for a total of 1 L) rather than oral lactulose. 1
• Alternatively, polyethylene glycol may be used if the patient is at risk of abdominal distention from lactulose. 1
• Monitor for precipitating factors of encephalopathy including infections, GI bleeding, acute kidney injury, and electrolyte disorders. 1

Address the Gallbladder Hydrops

• The asymptomatic gallbladder hydrops itself does NOT require surgical intervention at this time. 6
• Approximately 80% of patients with gallstones remain asymptomatic throughout their lives, and prophylactic cholecystectomy is not indicated in asymptomatic elderly patients. 6, 7
• The perioperative risks of surgery in a 70-year-old woman outweigh the minimal annual risk (<1% per year) of developing complications from asymptomatic gallstone disease. 6, 2

Indications for Future Cholecystectomy

Operate Only If Symptoms Develop

• Laparoscopic cholecystectomy becomes indicated if the patient develops true biliary colic, acute cholecystitis, cholangitis, or pancreatitis. 6, 7
• Early surgery (within 7-10 days, ideally within 24 hours) is recommended if acute cholecystitis develops. 7
• High-risk features that would prompt elective cholecystectomy include porcelain gallbladder or gallstones larger than 3 cm—neither of which is mentioned in your case. 6

Common Pitfall

• Do NOT attribute nonspecific dyspeptic symptoms (bloating, belching, fatty food intolerance) to the gallbladder hydrops; these symptoms rarely improve after cholecystectomy. 6

Patient Education and Follow-Up

• Educate the patient to seek immediate medical attention if she develops fever, jaundice, persistent nausea/vomiting, or severe right upper quadrant pain. 6
• Routine imaging surveillance of asymptomatic gallbladder hydrops is unnecessary; imaging should be reserved for symptom development. 6