Makindo Medical Notes

💡 About

• Gallstone ileus is a rare but important cause of small bowel obstruction, accounting for 1–4% of SBO cases (higher in the elderly).
• Occurs when a cholecysto-duodenal fistula forms between the gallbladder fundus and the adjacent duodenum due to chronic inflammation.
• A large gallstone (>2.5 cm) passes into the bowel lumen, most often lodging in the terminal ileum where the lumen narrows, causing mechanical obstruction.
• Predominantly affects elderly women with long-standing gallstone disease.

⚠️ Symptoms and Signs

• ⏳ Subacute or intermittent obstruction — "tumbling obstruction" as the stone moves along the bowel before lodging.
• 😣 Colicky abdominal pain, distension, constipation/obstipation.
• 🤢 Vomiting (may be bilious initially, later faeculent in advanced obstruction).
• 📜 Past history of gallstones or flatulent dyspepsia often present.
• 👵 Seen most commonly in elderly females with no prior abdominal surgery (important clue as adhesions are the leading SBO cause in younger patients).

🧪 Investigations

• 📸 Abdominal X-ray (AXR): May demonstrate Rigler’s triad:
  • Dilated small bowel loops (SBO).
  • Air in the biliary tree (pneumobilia).
  • Aberrant gallstone within the intestinal lumen.
• 🧲 CT Scan (gold standard): More sensitive in detecting pneumobilia, transition point, and the ectopic stone.
• 🔬 Bloods: May show dehydration, electrolyte disturbance, or raised inflammatory markers if secondary infection present.

🛠️ Treatment

• 🚑 Resuscitation first: IV fluids, correction of electrolytes, NG tube for decompression.
• 🔪 Laparotomy with enterolithotomy: Removal of the obstructing gallstone via enterotomy. Sometimes the stone can be ‘milked’ into the caecum and removed without enterotomy.
• ⚖️ One-stage vs two-stage surgery:
  • One-stage: Enterolithotomy + cholecystectomy + fistula repair (rarely done in acutely unwell elderly due to high risk).
  • Two-stage (common): Enterolithotomy to relieve obstruction, with delayed cholecystectomy if gallbladder symptoms persist.
• 📉 Mortality remains high (~15–20%) due to elderly, frail patient population and late presentation.

💡 Clinical Pearl: Always consider gallstone ileus in an elderly woman with SBO but no previous abdominal surgery. The classic triad on AXR is diagnostic but only seen in ~30–50% of cases. CT is the investigation of choice.