An uncommon etiology of small bowel obstruction: Gallstone ileus

Abstract

Gallstone ileus is a rare etiology of small bowel obstruction, occurring typically in the elderly population. The delay in diagnosis often results in significant morbidity and mortality. Here, we describe a case of 67 year old woman who presented with non specific abdominal symptoms and on evaluation was found to have small bowel obstruction caused by wedging of a large gallstone at the terminal ileum.

Gallstone Ileus: An Unusual Cause of Intestinal Obstruction

“…The nature of the obstruction often results in non-specific and intermittent signs and symptoms. Clinical examination is consistent with a bowel obstruction, dehydration, nausea, vomiting, abdominal distension, pain and high-pitched bowel sounds, which are most commonly present [2,4,9]. Patients may delay in presenting in part due to the "tumbling phenomenon".…”

“…Pericholecystic inflammation results in the formation of adhesions between the gallbladder and the gastrointestinal tract, usually the duodenum, due to proximity. The pressure effect of the gallstone results in erosion of the stone through the gallbladder wall into the intestine forming the fistula tract as presently demonstrated [2,4]. The formation of a biliary-enteric fistula allows the entry of gallstones into the gastrointestinal system and complicates 0.3%-1.5% of cases of cholelithiasis [1].…”

“…Most stones lodge in the ileum (60.5%), the narrowest segment of the bowel; reduced peristalsis in this area has also been suggested to be a contributing factor. Stones may also lodge in the jejunum (16.1%), stomach (14.2%) and less commonly the duodenum (3.5%) [1,2,4,6]. Most reported cases of obstruction demonstrate a gallstone larger than 2 cm in diameter, with smaller stones potentially able to pass through the intestine to the rectum [2][3][4]7,8].…”

“…Patients may delay in presenting in part due to the "tumbling phenomenon". It describes the intermittent nature of symptoms secondary to temporary gallstone impaction followed by symptom relief when the stone dislodges, travels distally and impacts again [1,2,4,10]. While the reported patient had no history of cholelithiasis, up to 30% of cases present with concurrent acute cholecystitis at the time of obstruction [2].…”

High small bowel obstruction from a gallstone

“…This phenomenon is called "tumbling obstruction''. Unsurprisingly, only large stones can produce symptoms of obstruction, particularly those exceeding 2.5 cm in dimension, since smaller stones can pass through the bowel without being impacted [14].…”