Gallstone Ileus: Diagnostic Pitfalls and Therapeutic Successes

Abstract

Gallstone ileus is a surgical emergency that occurs almost exclusively in the elderly. It is of increasing significance with current demographic changes. Clinical records and diagnostic imaging of 15 consecutive patients treated for gallstone ileus at one hospital over a 6-year period were reviewed. The median patient age was 80 years. Six plain-film diagnoses were made correctly. Contrast studies provided a diagnosis of intestinal obstruction in four patients. Abdominal X-ray findings were assessed incorrectly in two patients, with one false-positive and one false-negative result. The median preoperative hospital stay was 2 days. Three patients had Bouveret's syndrome, two of whom required a gastrostomy and enterolithotomy, and one of whom required a gastroenterostomy. The remaining 12 patients underwent enterolithotomies. Only one patient underwent a cholecystectomy. There was one postoperative death. No patient had biliary symptoms on follow-up. Gallstone ileus is a difficult clinical and radiologic diagnosis. Enterolithotomy alone is adequate treatment in the elderly, and subsequent cholecystectomy is not mandatory.

Gallstone ileus: correlation between computed tomography, double-balloon enteroscopy and intra-operative findings

“…In high risk patients, it is recommended to perform enterolithotomy alone, followed by elective cholecystectomy at a later date if biliary symptoms persist. However, in the elderly patient, subsequent cholecystectomy is not mandatory [7,11,12].…”

A rare cause of ileus: Gallstone ileus

“…Gallstone ileus usually occurs through bilioenteric fistulas caused by gallstones bigger than 2.5 cm of diameter eroding and perforating the bladder wall. Cholecystoduodenal fistulas were detected in 68% of patients with gallstone ileus 7 . In our case of a 78 year old female patient; the diameter of the stone which caused the obstruction was 4 cm, and it was located in terminal ileum.…”

Qual o seu diagnóstico?

“…Habitualmente não se atua na causa biliar na primeira etapa, para não se estender no tempo cirúrgico nos pacientes mais idosos, e, em geral, estes permanecem assintomáticos, podendo ocorrer até o fechamento espontâneo da fístula no pós-operatório (3) . Alguns pacientes podem necessitar de uma segunda abordagem para a realização de colecistectomia, por causa de sintomas relacionados à calculose (1) .…”

“…Em resumo, o íleo biliar é uma doença que deve ser considerada em pacientes, particularmente os idosos, que apresentam quadro clínico-abdominal obstrutivo agudo (3) , associado a alguns achados radiológicos característicos (sinais de distensão delgada, pneumobilia e cál-culos ectópicos), cujo diagnóstico precoce permite pronta terapia e evolução mais favorável.…”