Gallstone Obstruction

Enterolithiasis

“…A rare cause of estimated 1%-3% of mechanical small bowel obstructions, its significance raises tremendously in the elderly population where it accounts of up to a quarter of all small bowel obstructions [32] . First described by Bartholin in 1654 [34,37] , this syndrome gained attention with Dr. Rigler's classic paper in JAMA in 1941 [69] . Typical pathogenesis of gallstone ileus begins with acute or chronic cholecystitis, often in the setting of cholelithiasis, which spreads inflammation and adhesion to the alimentary tract, leading to development of a biliary-enteric fistula.…”

“…Typical pathogenesis of gallstone ileus begins with acute or chronic cholecystitis, often in the setting of cholelithiasis, which spreads inflammation and adhesion to the alimentary tract, leading to development of a biliary-enteric fistula. Given the anatomic proximity of the duodenal wall, cholecystoduodenal fistula accounts for overwhelming majority (86%-96%) of the tracts, followed by cholecysto-colonic, cholecysto-gastric, and choledocho-duodenal fistulas [33,34,57,[69][70][71][72][73][74] . Gallstones eventually enter the intestinal tract and may result in clinical obstruction with classic predilection to known areas of stasis in the physiologically narrower distal ileum and ileocecal valve (in 60% to 85% of the cases), proximal small intestine, stomach, and finally colon [34,37,38] .…”

“…Chemical analysis of the composition of enterolith reveals it gallstone origin; however, secondary depositions may occur in the long standing occult disease and vary by location. Size of the gallstones typically varies between 2.5 to 4.5 cm, but may achieve significantly large dimensions of 10 cm in some patients [34,69] . Reactive substances in the bile juice found in the gallstones may react with intestinal epithelial cells, potentially leading to significant mucosal injuries.…”

“…A quarter of cases will have an antecedent gallstone disease [34] . Classic description by Leo Rigler in 1941 of pneumobilia or contrast medium in the biliary tract, partial or complete small bowel obstruction, and a visualized ectopic gallstone that may change position within the bowel (Rigler's triad) [69] is seen in less than 50% of patients with gallstone ileus [31,34,36,38,57,69,73,79,80] . Combined radiologic imaging (X-rays, ultrasound, CT scan) result in increased yield of diagnosis, with positive findings in nearly 80% of the patients [34] .…”

Management Options of Bouveret's Syndrome

“…The triad of stomach distension along with imaging confirmation of a stone in the duodenum and air in the right upper quadrant is diagnostic of Bouveret's syndrome and occurs in a third of cases [8]. Gallstones giving rise to gastric outlet obstruction may also be diagnosed at endoscopy where a dilated stomach and hard mass at the site of the obstruction may be found [7].…”