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Gallstone Ileus with Cholecystoduodenal Fistula
BM Subnis*, Vinaya Ambore**, Waqar Ahmed Ansari***, Dinesh Joshi+, Parag Kumthekar+,
Sheetal Patil+, Tushar Bhagwat+, Alagappan+
 

A 75 year old male presented with complaint of pain in abdomen, colicky in nature, associated with distension, vomiting and obstipation since 4 days. Patient was also having breathlessness because of distension of abdomen as well as due to COPD. The diagnosis of cholecystoduodenal fistula leading to Gall stone ileus was confirmed. Post operative analysis of stone confirmed Gall stone

Introduction
Gall stone ileus is an unusual complication of cholelithiasis, occurring in less than 0.5% of patients. It is responsible for 1 to 4% of all cases of mechanical obstruction and in patients over the age of 65 years account for 25% of nonstrangulated bowel obstruction. The fistula between gall bladder and duodenum is commonest, followed by other parts of gastrointestinal tract. Obstruction is usually seen with stone greater than 2.5 cm. Site of obstruction is distal ileum i.e. 2 feet proximal to Ileo-caecal junction, followed by jejunum and stomach. Presenting feature comprises of Rigler’s triad of small bowel obstruction, pneumobilia and ectopic gall stone. Treatment is directed for intestinal obstruction i.e.to remove the calculus if it is hard or crush it within the lumen of bowel without opening it. The fistulous tract is left without disturbing it.

Case Report
A 75 years old male presented with coliky abdomen pain, vomiting 5 to 6 times in a day, distension of abdomen and obstipation since 4 days. Patient was having breathlessness. Patient was diagnosed as acute intestinal obstruction (Fig. 1) at referring hospital but surgery was not possible there because of very high risk associated with surgery and hence he was referred to us. On General examination, patient was breathless with respiratory rate of 34/min, Pulse – 110/min, blood pressure 100/70 mm of Hg. Per abdominal examination revealed generalized tenderness and distension of abdomen with hyperperistaltic sounds.

X-ray abdomen in standing position showed few air fluid levels. Anticipating the risk associated with laparotomy, we thought of diagnosing the cause of obstruction by doing USG. USG abdomen, revealed multiple dilated hyperperistaltic bowel loops and a foreign body in right paraumbilical region and gall bladder was collapsed. Till now we were in doubt about the diagnosis. Hence decision to do C.T. was taken. C.T. report revealed a small hypodense, well defined rounded lesion of 3 x 3 cm. with arc calcification in distal loop of ileum causing obstruction with dilatation of proximal small bowel, and pneumobilia, which was retrospectively seen in plain X-ray abdomen (Figs. 2-4).

Because of acute intestinal obstruction, patient was taken for exploratory laparotomy with high risk consent. On table, about 3 x 3 cm. stone in ileum 2 feet proximal to ileo caecal junction was seen. Enterolithotomy was done (Figs. 5-8). Cholecystoduodenal fistula was demonstrated, but was left without disturbing it. Chemical analysis of Gall Stone revealed cholesterol stone.

Patient stood the procedure well. But because of chronic pulmonary obstructive disease, patient had burst abdomen in the ward on 6th day and then he developed electrolyte imbalance, hyponatraemia / hypokalaemia and he expired in the ward on 10th day. It is known that Gall stone ileum is associated with very high mortality.

Fig. 1 : X-ray abdomen AP view showing air fluid level and pneumobilia. Fig. 2 : C.T. Scan abdomen showing small bowel obstruction and pneumobilia.

Discussion
Gall stone ileus is mechanical obstruction due to impaction of Gall stone in any part of gastrointestinal tract, most common site is distal ileum, usually 2 feet proximal to Ileo caecal junction .1 Other sites of obstruction are junction of second and third part of duodenum (Bouveret's sign),2 duodenojejunal flexor, pathological strictures in small bowel and, ileo caecal junction. It accounts for approximately 25% of all cases of small bowel obstruction over 65 years of age and about 1-4% of all cases of mechanical obstruction. It is more commonly seen in females.

Fig. 3 : C.T. scan showing ectopic gall stone completely obstructing the small bowel with proximal small dilatation. Fig. 4 : C.T. scan abdomen showing pneumobilia

The fistula of gall bladder to gastrointestinal tract occurs in 2-3% of all cases of cholelithiasis. The inflammation, leading to adhesion of gall bladder to either duodenum, stomach or colon leads to later on erosion of adherent walls and fistula formation. Only cholecystocolonic fistula can manifest other than intestinal obstruction also, e.g. Intractable diarrhoea, cystoduodenal fistulas manifest with obstruction only or may remain asymptomatic.

The obstruction of small bowel due to stone usually occurs when its diameter is more than 2.5 cm.
Clinical manifestation of Gall stone ileus are Rigler’s classical triad of small bowel obstruction, pneumobilia and ectopic gall stone. X-ray abdomen shows signs of small bowel obstruction but may not show Gall stone as majority of them are cholesterol stones and are non calcified. Pneumobilia may be seen, but it is present only in one third of cases. Absence of pneumobilia and nature of shadowing in the Gallbladder fossa remains a problem for ultrasound diagnosis of Gall stone ileus.3 C.T. on the other hand is good investigation to confirm the presence of Gall stone in small bowel lumen, pneumobilia and also to demonstrate fistula.4,5 Therefore early C.T. is must in diagnosis of Gallstone ileus, which is associated with high morbidity and mortality.

Treatment of Gall stone ileus is directed to remove the Gall stone by doing transverse enterolithotomy either by open laparotomy or by laparoscopic method.6 Fistula itself is left like that without disturbing it.

Fig. 5 : Intraoperative picture showing ileum with gallstone. Fig. 6 : Site of Gall stone i.e. two feet proximal to Ileo caecal junction.
Fig. 7 : Enterolithotomy Fig. 8 : Intraoperative view showing Gall Bladder adherent to first part of duodenum.

References

  1. Marc Christopher Winslet. Intestinal obstruction. Baily and love’s short practice of surgery: 23rd edition: R. C. G. Russell, N. S. Williams, C. J. K. Bulstrode 2000: 1066.
  2. SM Nielsen, PT Nielsen. Gastric retention caused by gallstones (Bouveret’s syndrome). Acta Chirurgica Scandinavica, Stockholm, 1983; 149 : 207–8.
  3. Keeling – Roberts CS. Gallstone IIeus: CT findings (letter; comment). Clin Radiol 1999; 54 (3) : 197.
  4. Rivadeneira DE, Curry WT. Images of Interest – Gastrointestinal: Gallstone Ileus. J Gastroenterol Hepatol 1994; 16 : 105.
  5. Swift SE, Spencer JA. Gallstone Ileus: CT findings, Clin Radiol 1998; 53: 451–4.
  6. Montgomery A. Laparoscope – guided enterolithotomy for gallstone ileus. Surg Laparosc Endosc 1993; 3 : 310–4. [Medline].