Spontaneous resolution of gallstone ileus in a patient with a previous jejunostomy and cholecystoduodenostomy

A 91-year-old woman with dark brown vomiting and abdominal pain with no evacuation in the past two days. She had a history of previous jejunostomy and a cholecystoduodenostomy. The physical exam revealed reduced bowel sounds, diffuse abdominal pain and abdominal distention. C-reactive protein (CRP) levels were mildly elevated.

Spontaneous resolution of gallstone ileus during patient´s hospital admission. On the first day (Fig. 1), enlarged small bowel loops, due to a mechanical obstruction secondary to a gallstone located in the proximal ileum were diagnosed in the i.v. contrast-enhanced abdominopelvic CT-scan. It is possible to see that the gallstone is hypodense and that there is a retrograde dilatation of the proximal loops with an abrupt reduction of diameter distal to the gallstone. Proximal ileum is a typical place of obstruction due to the anatomical narrowing of the lumen in this segment. During the follow-up, progression of the gallstone to terminal ileum was observed with persistent distension of small bowel loops in the oral and i.v. contrast-enhanced CT-scan that was performed after 4 days (Fig. 2). In the oral and i.v. contrast-enhanced abdominopelvic CT-scan performed on the 7th day, a spontaneous resolution of the mechanical obstruction was observed. Gallstone was situated in the sigmoid colon without any sign of bowel obstruction (Fig. 3). Once gallstone crosses the ileocecal valve, the possibility of spontaneous resolution increases.

Gallstone ileus is a rare cause of bowel obstruction whose mortality is set to be up to 30% [1]. This entity normally affects the elderly population. Gallstone ileus is, in fact, a mechanical obstruction of the bowel rather than a paralytic ileus being its name technically incorrect. 

This type of obstruction accounts for 1-4% of all causes of mechanical bowel obstruction and up to 25% of all bowel obstruction in patients over 65 [1]. This entity is more prevalent in Caucasian women [2]. Gallstone ileus is an obstruction of the small or large bowel due to the impaction of one or more gallstones. The stones density can be variable and not always calcify (as in this case). They should normally be greater than 2.5 cm in diameter and typically migrate to the bowel via bilioenteric fistula [1] being the bilioduodenal fistula the most common (85%). Typical places for gallstones to be lodged include the ileum and ileocecal valve due to the anatomical narrowing of the lumen in 60% of cases, jejunum in up to 16%, stomach in 15%, and colon in 2–8% of cases [3].

The clinical presentation is non-specific, depending on the gallstone site of impactation and the patient situation (it is important to remark that these patients normally have a wide range of comorbidities).  Patient´s case, for example, had a cholecystoduodenostomy due to a previous acute cholecystitis and the contraindication of surgery. After this intervention, a wider-than-expected communication between the gallbladder and the distal portion of the common bile duct with the proximal duodenum could have been developed, simulating a typical bilioduodenal fistula.

Classic clinical signs are abdominal pain, nausea, vomiting, abdominal distension, signs of bowel perforation, anorexia, hypotension, fever, high-pitched bowel sounds, etc.

Blood tests at the time of presentation with gallstone ileus tend to be unremarkable (unless signs of intra-abdominal sepsis were present), and the diagnosis is usually made with radiological imaging. 

Computed tomography (CT) scan is widely accepted as the study of choice in most cases of bowel obstruction. Contrast-enhanced CT for diagnosis of gallstone ileus has a sensitivity of 90–93% [1].

The classic radiologic signs of gallstone ileus constitute the Rigler triad [4]: 

-Pneumobilia

-Bowel obstruction 

-Ectopic gallstone

It is important to rule out free fluid, pneumoperitoneum, portal venous gas, or intestinal pneumatosis as signs of a poor prognosis.

Initially, the therapeutic approach is based on nasogastric tube placement (if bowel obstruction is stablished) and fluidotherapy. As in the case presented, spontaneous resolution of the gallstone ileus is possible [5] (Figures 1-3). However, in most patients, surgical management is required.

Take home message

Gallstone ileus is a rare complication of gallstone disease with a wide range of clinical presentations. The degree of suspicion is higher in elderly patients with signs of bowel obstruction. Despite plain abdominal X-ray is useful in the initial clinical approach, contrast-enhanced CT-scan is the modality of choice focusing on identifying the site of bowel obstruction and detecting potential complications.