Gallstone ileus

Clinical History

A 54-year-old woman with breast cancer, mastectomy and breast reconstruction of the abdominal tissue was hospitalised for suspicion of kidney stones on the left side. She had colic pain in the upper abdomen through one day, which became constant and somehow localised in the left flank, accompanied by vomiting.

Imaging Findings

A low-dosis non-contrast-enhanced CT examination of the abdomen (Fig. 1a, b, c) did not show free gas, free fluid, urolithiasis or ureterolithiasis, but it showed dilated small bowel loops proximal to a rim-calcified stone, measuring 2 x 2 x 2.5 cm, located in the hypogastric-region. A collapsed and very thick-walled gallbladder including a small air-bubble was observed. All these findings could represent a mechanical small bowel obstruction secondary to gallstone, in which the gallstone had migrated through a fistula to the small bowel. There was no history of gallstones. The gallstone was removed with an uncomplicated laparoscopy and the patient was discharged the day after the operation.
A retrospective review of the CT angiography of the abdomen, which was called a ''CT- breast-reconstruction'' in the first place, showed the same calculus in the gallbladder.

Discussion

Gallstone ileus is a rare complication of cholelithiasis that was first described by a Danish physician, Bartholin, in 1654 [1]. It is caused by a gallstone that has migrated to the gastrointestinal tract through a fistula. A fistula is usually formed between the gallbladder and the duodenum and it usually impacts in the terminal ileum. It is most often seen in the elderly population. Based on the fact that cholelithiasis disease is mostly seen in women, the majority of patient with gallstone ileus are female [2, 3, 4].
Symptoms depend on the different clinical types of gallstone ileus, which are acute, subacute and chronic. Patients can have history of cholecystitis attacks, abdominal pain, nausea, vomiting and sometimes haematemesis. Non-specific clinical symptoms and signs usually delay the diagnosis, which can induce the mortality. Besides the clinical examinations, radiological findings are essential to make the diagnosis. Abdominal plain radiography, ultrasound (US) and contrast-enhanced CT scanning (CECT) are the most useful modalities. Rigler triad (small bowel obstruction, gas within the biliary tree and an ectopic gallstone, which usually is located in the right iliac fossa) is the classic finding in plain radiography [5, 6].
US can detect free fluid, bowel occlusion, chronic cholecystitis, gas within the biliary tree (pneumobilia), ectopic gallstone, residual gallstones and cholecystointestinal fistula [5, 6].
Combination of abdominal ultrasound and plain radiography increases the diagnosis sensitivity up to 74% [5].
CT has a sensitivity around 93%, specificity around 100% and an accuracy around 99% [4]. CT can better visualise Rigler triad. Gas in the gallbladder, chronic cholecystitis, cholecystointestinal fistula and local inflammation can be observed in CT. Free gas, free fluid, porto-venous gas or mural gas are associated with poorer prognosis [5, 6, 7].
Treatment varies between the classical surgical procedures, laparoscopic procedures, interventional endoscopy and the medical treatment (only if the gallstone is smaller than 2cm) [5].
Risk of recurrent gallstone ileus is about 5% with a 20% rate of mortality. It is usually seen within 30 days after the first episode and is due to presence of undiagnosed stones in the gastrointestinal tract at the time of the first episode or because of a new migrated stone, through an untreated cholecystointestinal fistula [8].
Mortality is still high based on the fact that gallstone ileus is most often seen in the elderly population who usually have other comorbidities, and on the other hand the late diagnosis [5].
Take home massage:
1 - If you see Rigler triad, then think of gallstone ileus.
2 - Calculi are not always solitary. Look extra for other calculi to avoid recurrent ileus.

Differential Diagnosis List

Final Diagnosis

Gallstone ileus

URL:	https://eurorad.org/case/14859
DOI:	10.1594/EURORAD/CASE.14859
ISSN:	1563-4086