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ABDOMINAL IMAGING Table of Contents   
Year : 2002  |  Volume : 12  |  Issue : 3  |  Page : 349-351
Images : Gallstone Ileus


Dept of Radiology & Imaging North West Armed Forces, Hospital, P O Box 100, Tabuk, Saudi Arabia

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Keywords: Gallstone Ileus, Intestinal Obstruction

How to cite this article:
Shahat A H, Obaideen A M, Pandey U C. Images : Gallstone Ileus. Indian J Radiol Imaging 2002;12:349-51

How to cite this URL:
Shahat A H, Obaideen A M, Pandey U C. Images : Gallstone Ileus. Indian J Radiol Imaging [serial online] 2002 [cited 2020 Aug 8];12:349-51. Available from: http://www.ijri.org/text.asp?2002/12/3/349/28479

   Introduction Top


Gallstone ileus is a mechanical obstruction caused by impaction of gallstone(s) in any part of the gastrointestinal tract. It accounts for up to 25% of all cases of small bowel obstruction over 65 years of age.

The gallstone enters the gastrointestinal tract through a fistula between a gangrenous gallbladder and duodenum or other parts of the gastrointestinal tract. Occasionally stone may come into the intestine through a fistulous communication between the bile duct and the gastrointestinal tract. Intestinal obstruction is usually caused when the gallstones are greater than 2.5 cm in diameter.

The most common site of impaction of gallstones is in the distal ileum, followed by jejunum and stomach. Presenting features may be non-specific, but radiological findings comprising of Rigler's classic triad of small bowel obstruction, pneumobilia and ectopic gallstones may be occasionally detected by plain radiograph or ultrasound (US). Computed tomography (CT) invariably demonstrates a fistulous communication, intraluminal gallstone in the small bowel, pneumobilia and any other co-existing pathology contributing to the impaction of the gallstone.


   Case Report Top


A 61-year-old male had been unwell for 10 days with progressive abdominal pain and intermittent vomiting.

Plain abdominal x-rays revealed distended loops of small bowel consistent with partial small bowel obstruction and gas in the biliary tree and gallbladder [Figure - 1]. US confirmed gas in the biliary tree, but could not identify the gallbladder and could not determine the cause of intestinal obstruction.

A spiral CT examination showed abnormal gas in the gallbladder fossa, cholecystoduodenal fistula, abnormal duodenum and gas in the biliary tree [Figure - 2],[Figure - 3],[Figure - 4],[Figure - 5]. Two laminated calcified masses were present in the jejunal lumen and there were features of partial jejunal obstruction [Figure - 6],[Figure - 7]. These features suggested a diagnosis of gallstone ileus

At laparotomy two stones measuring 3.5 cm and 1.5cm in diameter were extracted from the jejunum. The bigger stone was impacted in the jejunal lumen approximately 50 cm from the duodenojejunal flexure. The smaller stone was floating freely in the proximal dilated loop of jejunum. The intestine was collapsed distal to the site of stone impaction.

The gallbladder fossa was examined and cholecystoduodenal fistula was left intact. The patient remained well on follow up after 6 months.


   Discussion Top


CT is increasingly used in cases of small bowel obstruction to look for features of ischaemia and strangulation and to seek evidence of underlying inflammatory mass [1]. The symptoms and signs of gallstone ileus are vague and recognition of this condition is vital in the elderly, given its high mortality [2].

Plain x-ray of the abdomen may be helpful if it reveals features of intestinal obstruction, shows calcified gallstone in the intestinal lumen or air in the biliary system. Pneumobilia is present in only one third of cases, as occlusion of the cystic duct or common bile duct results from inflammatory process within the gallbladder. The gas in the gallbladder fossa is not always recognized in plain abdominal radiography and recognition of gallstones in the intestinal lumen depends upon the density of calcium in the stone [2],[4].

Ultrasound may provide a definitive diagnosis of gallstone ileus and obviate the need for further tests. The presence of gas in the gallbladder and biliary tree is striking and at times it is possible to trace a dilated loop of the small bowel to the obstructing calculus and identify the exact site of the obstruction. However, the gallstone may lie much deeper in the abdomen, below the reflective loops of bowel and as such cannot be identified by ultrasound. Gas in the gallbladder fossa is also not often recognized. Absence of pneumobilia and 'nature' of shadowing in the gallbladder fossa remains a problem for ultrasound diagnosis of gallstone ileus [3]. CT, on the other hand, can demonstrate features of gallstone ileus including cholecystoduodenal fistula and the intraluminal gallstone in the bowel, even when this is not heavily calcified [2],[4],[5]. Our case demonstrates all the features of gallstone ileus on CT including cholecystoduodenal fistula, size and number of stones in the intestinal lumen and site of intestinal obstruction. The digital abdominal radiography taken during CT examination for orientation depicted the distended bowel, gas in the gallbladder fossa and pneumobilia with equal efficiency as routine plain x-ray of abdomen. In conclusion, CT provides all of the specific findings of gallstone ileus that are incompletely and infrequently demonstrated by plain abdominal radiography or by ultrasound. Early use of CT in elderly people with clinical features of intestinal obstruction helps to identify gallstone ileus, which is associated with significant morbidity and mortality if left untreated.


   Acknowledgement Top


We would like to thank Mrs M Bool for her help with preparation of this manuscript

 
   References Top

1.Maglinte DDT, Balthazar EJ, Kelvin FM, Megibow AJ. The role of radiology in the diagnosis of small-bowel obstruction. Am J Roentgenol 1997; 168: 1171-1180.  Back to cited text no. 1    
2.Rivadeneira DE, Curry WT. Images of Interest - Gastrointestinal: Gallstone Ileus. J Gastroenterol Hepatol 1994; 16: 105  Back to cited text no. 2    
3.Keeling-Roberts CS. Gallstone Ileus: CT findings (letter; comment). Clin Radiol 1999; 54 (3): 197.  Back to cited text no. 3    
4.Swift SE, Spencer JA. Gallstone Ileus: CT findings, Clin Radiol 1998; 53: 451-454.  Back to cited text no. 4    
5.Scarpa Francis J, Borges James, Mullen David. Gallstone Ileus. Am J Surg 2000; 180: 99.  Back to cited text no. 5    

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Correspondence Address:
A H Shahat
Dept of Radiology & Imaging North West Armed Forces, Hospital, P O Box 100, Tabuk
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


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    Figures

[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7]

This article has been cited by
1 Gallstone ileus with cholecystocolonic fistula
Gelbman, A.
Emergency Radiology. 2006; 12(4): 199-200
[Pubmed]



 

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    Introduction
    Case Report
    Discussion
    Acknowledgement
    References
    Article Figures

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