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Emergency And Acute Medicine - Gallstone Ileus
Fundamental Overview
Clinical Description Mechanical intestinal obstruction caused by impaction of a gallstone within the bowel lumen. Stones are typically larger than 2.5 cm. Gallstone ileus accounts for 1–3% of all intestinal obstructions and occurs most commonly in patients older than 65 years. Females are affected more frequently than males with a ratio of approximately 5:1. Mortality remains high at 15–18%.
Underlying Causes
Chronic inflammation of the gallbladder leads to adhesion formation between the gallbladder and adjacent bowel. Over time, a cholecystoenteric fistula develops, allowing gallstones to migrate into the intestinal tract. The duodenum is the most common site of fistula formation, followed by the colon, while gastric fistulas are rare. Stone impaction most frequently occurs in the terminal ileum (54–65%), the narrowest segment of the small intestine at the ileocecal valve. Other sites include the jejunum (27%) and duodenum (1–3%). Duodenal impaction causing gastric outlet obstruction is referred to as Bouveret syndrome. Large bowel obstruction is uncommon.
Diagnostic Evaluation
Presenting Features And Symptoms Patients often experience “tumbling” abdominal pain characterized by intermittent discomfort as the stone moves through the bowel before becoming lodged. Complete obstruction results in severe and often acute abdominal pain. Common associated symptoms include nausea, bilious or feculent vomiting, obstipation, abdominal distention with tympany, abdominal tenderness with late peritoneal signs, and abnormal bowel sounds. Only 50–60% of patients report a prior history of biliary colic or known gallstone disease. Gallstone ileus is frequently associated with cardiovascular disease, diabetes, and obesity. Physical examination typically reveals abdominal distention and tenderness, and jaundice may be present.
Initial Assessment Requirements Evaluation should focus on confirming the presence of mechanical intestinal obstruction and identifying complications
.
Investigations And Interpretation
Laboratory Studies Electrolytes, blood urea nitrogen, creatinine, and glucose should be assessed due to dehydration and vomiting. Liver function tests and bilirubin may be elevated. Amylase may increase in late obstruction. Complete blood count and hematocrit may demonstrate hemoconcentration from dehydration, with nonspecific leukocytosis.
Imaging Studies
Upright and supine abdominal radiographs may show multiple air–fluid levels and bowel distention. The Rigler triad is diagnostic when two of three findings are present: pneumobilia, partial or complete bowel obstruction, and an ectopic gallstone. Chest radiography is used to assess for pneumoperitoneum. Abdominal CT scanning is the diagnostic modality of choice and allows direct visualization and localization of the obstructing stone. Abdominal ultrasound may identify pneumobilia and gallstones but is less sensitive for detecting the site of obstruction.
Conditions To Consider
Paralytic ileus, adhesive bowel obstruction, volvulus, hernia, intussusception, gastrointestinal malignancy, diverticulitis, bezoar, inflammatory bowel disease, pseudo-obstruction, cholecystitis, ascending cholangitis, and pancreatitis.
Management Approach
Prehospital Considerations Establish intravenous access as early as possible.
Early Stabilization Measures Initiate intravenous fluid resuscitation to correct dehydration and maintain hemodynamic stability.
Emergency Department
Management Insert a nasogastric tube for gastric and intestinal decompression. Maintain nil per os status. Correct electrolyte abnormalities and monitor urine output. Provide adequate analgesia. Begin broad-spectrum antibiotics covering bowel flora, such as piperacillin/tazobactam, ampicillin/sulbactam, or ticarcillin/clavulanate. Acceptable alternatives include carbapenems or a third-generation cephalosporin combined with metronidazole. Prompt surgical consultation is mandatory.
Pharmacologic Therapy
Ampicillin/sulbactam 3 g IV every 6 hours. Piperacillin/tazobactam 3.375 g IV every 6 hours. Ticarcillin/clavulanate 3.1 g IV every 4–6 hours.
Disposition And Follow Up
Indications For Admission All patients with gallstone ileus require hospital admission and urgent surgical evaluation for operative intervention.
Criteria For Discharge None.
Ongoing Care
Recommendations Immediate surgical consultation in the emergency department for definitive operative management.
Clinical Pearls And Common Errors
Gallstone ileus represents a true mechanical intestinal obstruction rather than a functional ileus. Definitive management requires urgent surgical intervention. Mortality is high due to delayed diagnosis and significant comorbidities in affected patients. Maintain a high index of suspicion in elderly patients, particularly women, presenting with bowel obstruction and no prior abdominal surgery. Plain radiographs detect only about 10% of ectopic gallstones, whereas CT imaging is significantly more sensitive. Only half of patients have a known history of biliary colic or gallstone disease.
Fundamental Overview
Clinical Description Mechanical intestinal obstruction caused by impaction of a gallstone within the bowel lumen. Stones are typically larger than 2.5 cm. Gallstone ileus accounts for 1–3% of all intestinal obstructions and occurs most commonly in patients older than 65 years. Females are affected more frequently than males with a ratio of approximately 5:1. Mortality remains high at 15–18%.
Underlying Causes
Chronic inflammation of the gallbladder leads to adhesion formation between the gallbladder and adjacent bowel. Over time, a cholecystoenteric fistula develops, allowing gallstones to migrate into the intestinal tract. The duodenum is the most common site of fistula formation, followed by the colon, while gastric fistulas are rare. Stone impaction most frequently occurs in the terminal ileum (54–65%), the narrowest segment of the small intestine at the ileocecal valve. Other sites include the jejunum (27%) and duodenum (1–3%). Duodenal impaction causing gastric outlet obstruction is referred to as Bouveret syndrome. Large bowel obstruction is uncommon.
Diagnostic Evaluation
Presenting Features And Symptoms Patients often experience “tumbling” abdominal pain characterized by intermittent discomfort as the stone moves through the bowel before becoming lodged. Complete obstruction results in severe and often acute abdominal pain. Common associated symptoms include nausea, bilious or feculent vomiting, obstipation, abdominal distention with tympany, abdominal tenderness with late peritoneal signs, and abnormal bowel sounds. Only 50–60% of patients report a prior history of biliary colic or known gallstone disease. Gallstone ileus is frequently associated with cardiovascular disease, diabetes, and obesity. Physical examination typically reveals abdominal distention and tenderness, and jaundice may be present.
Initial Assessment Requirements Evaluation should focus on confirming the presence of mechanical intestinal obstruction and identifying complications
.
Investigations And Interpretation
Laboratory Studies Electrolytes, blood urea nitrogen, creatinine, and glucose should be assessed due to dehydration and vomiting. Liver function tests and bilirubin may be elevated. Amylase may increase in late obstruction. Complete blood count and hematocrit may demonstrate hemoconcentration from dehydration, with nonspecific leukocytosis.
Imaging Studies
Upright and supine abdominal radiographs may show multiple air–fluid levels and bowel distention. The Rigler triad is diagnostic when two of three findings are present: pneumobilia, partial or complete bowel obstruction, and an ectopic gallstone. Chest radiography is used to assess for pneumoperitoneum. Abdominal CT scanning is the diagnostic modality of choice and allows direct visualization and localization of the obstructing stone. Abdominal ultrasound may identify pneumobilia and gallstones but is less sensitive for detecting the site of obstruction.
Conditions To Consider
Paralytic ileus, adhesive bowel obstruction, volvulus, hernia, intussusception, gastrointestinal malignancy, diverticulitis, bezoar, inflammatory bowel disease, pseudo-obstruction, cholecystitis, ascending cholangitis, and pancreatitis.
Management Approach
Prehospital Considerations Establish intravenous access as early as possible.
Early Stabilization Measures Initiate intravenous fluid resuscitation to correct dehydration and maintain hemodynamic stability.
Emergency Department
Management Insert a nasogastric tube for gastric and intestinal decompression. Maintain nil per os status. Correct electrolyte abnormalities and monitor urine output. Provide adequate analgesia. Begin broad-spectrum antibiotics covering bowel flora, such as piperacillin/tazobactam, ampicillin/sulbactam, or ticarcillin/clavulanate. Acceptable alternatives include carbapenems or a third-generation cephalosporin combined with metronidazole. Prompt surgical consultation is mandatory.
Pharmacologic Therapy
Ampicillin/sulbactam 3 g IV every 6 hours. Piperacillin/tazobactam 3.375 g IV every 6 hours. Ticarcillin/clavulanate 3.1 g IV every 4–6 hours.
Disposition And Follow Up
Indications For Admission All patients with gallstone ileus require hospital admission and urgent surgical evaluation for operative intervention.
Criteria For Discharge None.
Ongoing Care
Recommendations Immediate surgical consultation in the emergency department for definitive operative management.
Clinical Pearls And Common Errors
Gallstone ileus represents a true mechanical intestinal obstruction rather than a functional ileus. Definitive management requires urgent surgical intervention. Mortality is high due to delayed diagnosis and significant comorbidities in affected patients. Maintain a high index of suspicion in elderly patients, particularly women, presenting with bowel obstruction and no prior abdominal surgery. Plain radiographs detect only about 10% of ectopic gallstones, whereas CT imaging is significantly more sensitive. Only half of patients have a known history of biliary colic or gallstone disease.
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