Open Access Case

Report DOI: 10.7759/cureus.7284

Gallstone Ileus: An Unusual Cause of

Intestinal Obstruction
Tia Morosin 1 , Marie Shella B. De Robles 2 , Soni Putnis 1

1. Surgery, The Wollongong Hospital, Wollongong, AUS 2. Surgery, Philippine General Hospital, Manila,
PHL

Corresponding author: Tia Morosin, [email protected]

Abstract
Gallstone ileus is an uncommon complication of gallstones and a rare cause of intestinal
obstruction. Typically as a result of the formation of cholecystoduodenal fistula, surgical
removal of the gallstone is the mainstay of treatment in order to relieve the intestinal
obstruction. A 34-year-old male with no history of cholelithiasis presented with features of a
small bowel obstruction. CT scan of the abdomen demonstrated pneumobilia, a
cholecystoduodenal fistula and small bowel obstruction, features suspicious for a gallstone
ileus. The patient underwent a laparotomy and removal of two gallstones via an enterotomy.
He was discharged home after an uneventful post-operative period. Gallstone ileus is an
uncommon cause of mechanical bowel obstruction with often delayed presentation and non-
specific symptoms. A high level of suspicion is required in at-risk groups, and in patients
presenting with a bowel obstruction and known gallstone disease.

Categories: General Surgery

Keywords: gallstone ileus, cholelithiasis, cholecystoduodenal fistula, laparotomy, enterotomy,
intestinal obstruction

Introduction
Gallstone ileus is a rare cause of intestinal obstruction, occurring in less than 5% of patients
who present with a mechanical small bowel obstruction [1]. Gallstone ileus is an unusual
complication of cholelithiasis. It is caused by the impaction of a gallstone in the small bowel,
usually after passing through a biliary-enteric fistula typically formed between the gallbladder
and duodenum [2]. Female and older patients are disproportionality affected, and a high index
of suspicion should be needed when patients present with a bowel obstruction and known
history of gallstones [1,3]. Here we present a case of a gallstone ileus in a patient with no
preceding history who underwent a laparotomy with enterolithotomy.

Received 03/02/2020
Review began 03/08/2020 Case Presentation
Review ended 03/12/2020
Published 03/15/2020 A 34-year-old male presented with a one-day history of colicky epigastric pain and
vomiting. He also reported two days of constipation and not passing flatus. An otherwise
© Copyright 2020
Morosin et al. This is an open access
healthy male, he had no previous medical history, denied any previous biliary symptoms, no
article distributed under the terms of history of cholelithiasis and no previous abdominal surgery. He was haemodynamically stable
the Creative Commons Attribution and afebrile on presentation. Examination revealed a soft abdomen with moderate distension
License CC-BY 4.0., which permits and epigastric tenderness; however, no rebound tenderness or guarding was noted. Routine
unrestricted use, distribution, and
blood tests were unremarkable. CT of the abdomen demonstrated a small bowel obstruction
reproduction in any medium, provided
the original author and source are with the point of obstruction in mid abdomen and a cholecystoduodenal fistula suspicious for
credited. gallstone ileus; however, no radio-opaque stone was seen (Figures 1, 2).

How to cite this article

Morosin T, De Robles M B, Putnis S (March 15, 2020) Gallstone Ileus: An Unusual Cause of Intestinal
Obstruction. Cureus 12(3): e7284. DOI 10.7759/cureus.7284
 FIGURE 1: Dilation of intrahepatic ducts (white arrow),
pneumobilia (white arrow), contracted gallbladder with
thickened wall (blue arrow), dilated loops of small bowel (red
arrow)

2020 Morosin et al. Cureus 12(3): e7284. DOI 10.7759/cureus.7284 2 of 7

 FIGURE 2: Cholecystoduodenal fistula formation (white arrow)

He was resuscitated with intravenous fluids and had a nasogastric tube inserted for
decompression. The patient underwent a laparotomy. Intraoperative findings noted small
bowel obstruction with the transition point at 50 cm from the ileocaecal valve caused by two
large gallstones obstructing the lumen (Figure 3). A longitudinal 1 cm enterotomy was made
proximal to the distal gallstone (Figure 4). Both stones were removed (2 and 3 cm), and the
enterotomy was closed transversely. His post-operative period was uneventful, and the patient
was discharged home day 3 post-operatively.

2020 Morosin et al. Cureus 12(3): e7284. DOI 10.7759/cureus.7284 3 of 7

 FIGURE 3: Impacted gallstone (black arrow)

2020 Morosin et al. Cureus 12(3): e7284. DOI 10.7759/cureus.7284 4 of 7

 FIGURE 4: Small bowel enterotomy for removal of the impacted
gallstones (black arrow)

Discussion
Although labelled as an ileus, impaction of gallstones in the small intestine is a true
mechanical obstruction. It is rare in nature, accounting for less than 5% of mechanical
obstructions, and is associated with significant morbidity and mortality (overall 18%) [1]. It is
also an uncommon complication of cholelithiasis, occurring in 0.3%-0.5% of patients with
gallstones, most commonly the elderly and female population [1,3]. While not apparent in the
case presented, the majority of cases are preceded by acute cholecystitis resulting in the
formation of a biliary-enteric fistula. Pericholecystic inflammation results in the formation of
adhesions between the gallbladder and the gastrointestinal tract, usually the duodenum, due to
proximity. The pressure effect of the gallstone results in erosion of the stone through the
gallbladder wall into the intestine forming the fistula tract as presently demonstrated [2,4]. The
formation of a biliary-enteric fistula allows the entry of gallstones into the gastrointestinal
system and complicates 0.3%-1.5% of cases of cholelithiasis [1]. Alternatively, the gallstone
may pass through the common bile duct into the duodenum through the ampulla [2,5]. Most

2020 Morosin et al. Cureus 12(3): e7284. DOI 10.7759/cureus.7284 5 of 7

 stones lodge in the ileum (60.5%), the narrowest segment of the bowel; reduced peristalsis in
this area has also been suggested to be a contributing factor. Stones may also lodge in the
jejunum (16.1%), stomach (14.2%) and less commonly the duodenum (3.5%) [1,2,4,6]. Most
reported cases of obstruction demonstrate a gallstone larger than 2 cm in diameter, with
smaller stones potentially able to pass through the intestine to the rectum [2-4,7,8]. As
discovered in the present case, multiple gallstones may be present in up to 40% of cases [3]. The
nature of the obstruction often results in non-specific and intermittent signs and symptoms.
Clinical examination is consistent with a bowel obstruction, dehydration, nausea, vomiting,
abdominal distension, pain and high-pitched bowel sounds, which are most commonly present
[2,4,9]. Patients may delay in presenting in part due to the “tumbling phenomenon”. It
describes the intermittent nature of symptoms secondary to temporary gallstone impaction
followed by symptom relief when the stone dislodges, travels distally and impacts again
[1,2,4,10]. While the reported patient had no history of cholelithiasis, up to 30% of cases
present with concurrent acute cholecystitis at the time of obstruction [2]. Patients may also
present tachycardic, hypotensive and febrile, signs suggestive of sepsis from either
cholecystitis or peritonitis due to impaction of the gallstone causing pressure to the bowel wall,
necrosis and perforation [2]. Biochemical markers may be unremarkable or non-specific and
may include leukocytosis and deranged electrolytes [3,10]. As such, a high level of suspicion in
patients with a history of gallstones presenting with a bowel obstruction is required. Rigler’s
triad describes classical features seen on imaging suggestive of gallstone ileus: (1) intestinal
obstruction, (2) pneumobilia, (3) gallstone within the intestinal lumen and, more recently, a
change in position of the gallstone on serial imaging [11]. Apart from traditionally x-ray
findings, the features are also apparent on CT abdomen scan, which, with sensitivity and
specificity of 93% and 100%, respectively, has become the gold standard [12]. A CT scan may
also help visualise the viability of the bowel, detect features of cholecystitis (although not
diagnostic) and, as in the current case, identify the presence of a biliary-enteric fistula, thereby
helping to guide the management of the patient. The aim of treatment is to relieve the
obstruction, which centres on removal of the gallstone. While there is consensus regarding the
need for enterolithotomy, there is controversy in the literature as to whether a
cholecystectomy and fistula repair should be performed concurrently. Of the two procedures,
there is a known increased risk of morbidity and mortality associated with a single-stage
procedure; however, there is also the risk of further complications from gallstones while
awaiting a cholecystectomy and repair of fistula in a two-staged procedure [2-6,9].
Intraoperatively, our patient was noted to have a chronically inflamed and contracted
gallbladder with a large fistula tract. Consequently, we elected for a staged procedure with a
laparotomy and enterolithotomy during the initial presentation.

Conclusions
Gallstone ileus is an uncommon cause of mechanical bowel obstruction with often-delayed
presentation and non-specific symptoms. As such a high level of suspicion is required in at-risk
groups and in patients presenting with a bowel obstruction and known gallstone disease.

Additional Information
Disclosures
Human subjects: Consent was obtained by all participants in this study. Conflicts of interest:
In compliance with the ICMJE uniform disclosure form, all authors declare the following:
Payment/services info: All authors have declared that no financial support was received from
any organization for the submitted work. Financial relationships: All authors have declared
that they have no financial relationships at present or within the previous three years with any
organizations that might have an interest in the submitted work. Other relationships: All
authors have declared that there are no other relationships or activities that could appear to
have influenced the submitted work.

2020 Morosin et al. Cureus 12(3): e7284. DOI 10.7759/cureus.7284 6 of 7

 References
1. Reiner RM, Cohen JR: Gallstone ileus: a review of 1001 reported cases . Am Surg. 1994, 60:441-
446.
2. Niño-Guzman CM, Marin-Contreras ME, Figueroa-Sanchez M, Corona JL: Gallstone ileus,
clinical presentation, diagnostic and treatment approach. World J Gastrointest Surg. 2016,
8:65-76. 10.4240/wjgs.v8.i1.65
3. Clavien PA, Richon J, Burgan S, Rohner A: Gallstone ileus. Br J Surg. 1990, 77:737-742.
10.1002/bjs.1800770707
4. Verma A, Moonat A, Adoll L: An uncommon etiology of small bowel obstruction: gallstone
ileus. J Hosp Med. 2010, 5:E21-E22. 10.1002/jhm.582
5. Pezzoli A, Maimone A, Fusetti N, Pizzo E: Gallstone ileus treated with non-surgical
conservative methods: a case report. J Med Case Rep. 2015, 9:15. 10.1186/1752-1947-9-15
6. Hussain J, Alarashed AM, Alkhadher T, Wood S, Behbehani AD: Gall stone ileus: unfamiliar
cause of bowel obstruction. Case report and literature review. Int J Surg Case Rep. 2018,
49:44-50. 10.1016/j.ijscr.2018.06.010
7. Mirza Gari MK, Eldamati A, Foula MS, Al-Mulhim A, Abdulmomen AA: Laparoscopic
management for gallstone ileus, case report. Int J Surg Case Rep. 2018, 51:268-271.
10.1016/j.ijscr.2018.09.004
8. Abou-Saif A, Al-Kawas FH: Complications of gallstone disease: Mirizzi syndrome,
cholecystocholedochal fistula and gallstone ileus. Am J Gastroenterol. 2002, 97:249-254.
10.1111/j.1572-0241.2002.05451.x
9. Dai XZ, Li GQ, Zhang F, Wang XH, Zhang CY: Gallstone ileus: case report and literature
review. World J Gastroenterol. 2013, 19:5586-5589. 10.3748/wjg.v19.i33.5586
10. Abich E, Glotzer D, Murphy E: Gallstone ileus: an unlikely cause of mechanical small bowel
obstruction. Case Rep Gastroenterol. 2017, 11:389-395. 10.1159/000475749
11. Rigler LG, Borman CN, Noble JF: Gallstone obstruction: pathogenesis and roentgen
manifestations. JAMA. 1941, 17:1753-1759. 10.1001/jama.1941.02820470001001
12. Yu CY, Lin CC, Shyu RY, et al.: Value of CT in the diagnosis and management of gallstone
ileus. World J Gastroenterol. 2005, 11:2141-2147. 10.3748/wjg.v11.i14.2142

2020 Morosin et al. Cureus 12(3): e7284. DOI 10.7759/cureus.7284 7 of 7