Gallstone ileus
===============

* Anastasios Koulaouzidis MD
* John Moschos, MD PhD
* Shivaram Bhat, MB BCh
* Karthikeyan Gopal, MBBS

*   © 2008 Canadian Medical Association

An elderly woman in her 90s was admitted with signs and symptoms suggestive of obstructive ileus: crampy abdominal pain, repeated episodes of vomiting and increased bowel sounds with tympanic sound on percussion. A plain film radiograph (Figure 1) and computed tomography scans (Figure 2) of her abdomen confirmed Rigler's triad: ectopic gallstone, pneumobilia and small-bowel dilation. This patient's gallstone (2.5 × 3.5 cm) was lodged in the jejunum. Because the patient had concurrent disorders and was a poor operative candidate, we chose a conservative approach to treatment. Unfortunately, the patient died.

![Figure1](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/179/8/859/F1.medium.gif)

[Figure1](http://www.cmaj.ca/content/179/8/859/F1)

**Figure 1:** Radiograph of the abdomen of an elderly woman who was admitted with signs and symptoms suggestive of obstructive ileus. The film shows a gallstone within the bowel (black arrow) and dilated small-bowel loops (white arrows) consistent with obstruction.


![Figure2](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/179/8/859/F2.medium.gif)

[Figure2](http://www.cmaj.ca/content/179/8/859/F2)

**Figure 2:** Multidetector computed tomography scans, showing air in the biliary tree (A, arrows) and an ectopic gallstone in the intestinal lumen (B, arrows).

Gallstone ileus is a rare complication of gallstone disease. A small-bowel obstruction results after 1 or more gallstones migrate through a cholecystoenteric fistula.1 Elderly women are more likely than men to experience this complication for unclear reasons. Among patients with comorbidities, gallstone ileus has a mortality rate of up to 18%.2 In patients at low operative risk, staged laparoscopic management of gallstone ileus and of the associated cholecystoenteric fistula gives good results. For the majority of patients, though, laparotomy is the treatment of choice.

## REFERENCES

1.  1. Abou-Saif A, Al-Kawas FH. Complications of gallstone disease: Mirizzi syndrome, cholecystocholedochal fistula and gallstone ileus. Am J Gastroenterol 2002;97:249-54.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1111/j.1572-0241.2002.05451.x&link_type=DOI) 
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=11866258&link_type=MED&atom=%2Fcmaj%2F179%2F8%2F859.atom) 
    
    [Web of Science](http://www.cmaj.ca/lookup/external-ref?access_num=000173880400006&link_type=ISI) 

2.  2. Moschos J, Pilpilidis I, Antonopoulos Z, et al. Complicated endoscopic management of Bouveret's syndrome. A case report and review. Rom J Gastroenterol 2005;14:75-7.
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=15800698&link_type=MED&atom=%2Fcmaj%2F179%2F8%2F859.atom)