What is Gallstone Ileus?
Gallstone ileus is a rare complication caused by gallstones and is one of the least frequent causes of blockages in the intestine. Although uncommon, gallstone ileus is often seen as a cause of mechanical obstructions in the small intestine that do not cut off the blood supply. It accounts for 1% to 4% of all such cases and happens in up to 25% of elderly patients. The diagnosis is often delayed because symptoms may come and go, and tests may not be able to pinpoint the cause of the blockage. Therefore, gallstone ileus is still related to significant health risks and death rates.
This condition is typically treated with surgery, but the actual procedure used depends on the specific details of the case. Many patients who have gallstone ileus also have other health issues like heart and lung disease, which need to be taken into account. In some cases, a section of the intestine may need to be surgically removed.
What Causes Gallstone Ileus?
Dr. Erasmus Bartholin first described a condition known as gallstone ileus in 1654. This condition occurs when a gallstone, which usually forms in the gallbladder, gets stuck in the digestive tract after it passes through an abnormal connection between the bile and intestine (we call this a ‘biliary-enteric fistula’).
Gallstone ileus is more often seen in women (3.5 women for every man) and particularly in patients over the age of 60. Other factors that can contribute to gallstone ileus include having gallstones for a long time, experiencing repeated bouts of inflammation in the gallbladder (acute cholecystitis), and having gallstones larger than 2 cm.
From studies, we know that about 40% to 50% of patients who are diagnosed with gallstone ileus have had a recent history of gallbladder pain (biliary colic), a yellowing of the skin and eyes due to liver disease (jaundice), or acute inflammation of the gallbladder.
Risk Factors and Frequency for Gallstone Ileus
Gallstone ileus is a rare issue that affects a very small fraction of gallstone patients – anywhere from 0.3% to 0.5%. Among all cases of bowel obstruction, gallstone ileus is an extremely rare cause, accounting for less than 0.1% of instances. Even when considering just cases of non-strangulating small bowel obstructions, it only makes up 1% to 4%. Despite advances in medicine over the last 350 years, there’s still a fairly high mortality rate associated with gallstone ileus, ranging from 12% to 27%. This high death rate is partly because the symptoms can be unclear, routine biochemical tests may not highlight the issue, it’s often misdiagnosed, and tends to be found quite late.
Signs and Symptoms of Gallstone Ileus
Gallstone obstruction is a condition that is often challenging to diagnose. This difficulty arises because its symptoms might vary, occur on-and-off, or because medical tests have a hard time pinpointing the problem due to what’s called the “tumbling phenomenon.” This refers to how the gallstone moves unpredictably through different parts of the gut. Usually, patients will experience symptoms for 4 to 8 days before seeking medical attention.
Common signs and symptoms include stomach cramps, belly bloating, feelings of nausea, vomiting, and alternating constipation as the gallstone moves around the digestive tract. The severity can change depending on where the gallstone is within the gut, and surprisingly, sometimes the gallstone might even pass out through the rectum without the person noticing.
During a physical examination, the doctor might note a swollen belly, tenderness, unusual bowel sounds, and jaundice (a yellowing of the skin and eyes due to liver issues). It’s important to understand that the level of pain a person feels doesn’t always match the actual physical changes in the body.
Testing for Gallstone Ileus
Normally, the diagnosis of gallstone ileus, a condition where a gallstone blocks the intestine, is made between 3 and 8 days after symptoms start. However, only about 30% to 70% of the cases are diagnosed accurately before surgery. Therefore, doctors need to be highly alert for this condition. Standard lab tests usually don’t give clear results, as only about one-third of patients have symptoms like jaundice (yellowing of skin and eyes) or altered liver enzyme levels.
Although ultrasound can help in identifying complications like fistulas (abnormal connections between organs), air in the bile ducts, trapped gallstones, and leftover gallstones after surgery, it might not always locate the stones due to obstacles like bowel gas. Simple abdominal x-rays can be used for diagnosis as well, with some cases showing three signs (called Rigler’s triad): partial or full bowel obstruction, presence of air or contrast material in the bile ducts, and a misplaced gallstone that may appear in different places on successive x-rays. However, the sensitivity of x-rays ranges between 40% and 70%, meaning that they might miss the diagnosis in a considerable number of cases.
Computed tomography (CT) scans are more reliable and can correctly identify gallstone ileus in 93% of cases. Plus, it can pick up additional signs related to the disease like thickening of the gallbladder wall, air in the bile ducts, blockage in the intestine, and the obstructing gallstone itself. However, even CT scans may miss the condition in some patients, especially since some of the signs aren’t specific to gallstone ileus.
In such cases, if the doctor still suspects gallstone ileus but the x-ray results are negative, they may order additional tests like a hepatobiliary iminodiacetic acid (HIDA) scan, a magnetic resonance cholangiopancreatography (MRCP), or an esophagogastroduodenoscopy (EGD). However, often the diagnosis is only confirmed during surgery when the doctor is investigating the cause of small bowel obstruction.
Treatment Options for Gallstone Ileus
The treatment and management of gallstone ileus — a medical condition where stones from the gallbladder block the intestines — can sometimes be controversial. However, the main goal is always to remove the stone causing the blockage after initial medical treatment to stabilize the patient. There are three key parts to gallstone ileus: gallstones, a connection (fistula) between the bile duct and intestines, and a blockage in the intestine. Usually, doctors aim to remove the stone and cut off the fistula. Once the stone is removed, the blockage in the intestines is typically resolved.
Currently, there are three surgical procedures for treating gallstone ileus. The first is a simple operation to remove the stone (entero-lithotomy). The second is a single operation that removes the stone, takes out the gallbladder, and cuts off the fistula (one-stage procedure). The third is a two-part operation that removes the stone first and then removes the gallbladder later (two-stage procedure).
Many doctors believe that the best option for most patients is to simply remove the stone. If a patient is in good overall health and the initial medical treatment works well, some recommend a single operation to remove the stone, gallbladder, and cut off the fistula. A two-stage operation is typically considered for patients who have ongoing symptoms even after the stone is removed.
Whether the gallbladder should be removed during the same operation as the stone or later is still undecided.
Managing gallstone ileus with an endoscope is also possible. This procedure involves inserting a tube with a camera into the patient’s body to locate and remove the stone. However, this method is generally challenging and can involve risks such as bleeding. If the cut into the bowel to access the stone is large, closing it can be difficult.
Before any surgery, patients must receive fluids and electrolytes (minerals needed for body functions) to improve their overall health. For patients with other health issues in addition to gallstone ileus, admission to the intensive care unit (ICU) is often recommended.
What else can Gallstone Ileus be?
When trying to figure out if someone has gallstone ileus, doctors might consider similar conditions. These could include:
- Acute pancreatitis (sudden inflammation of the pancreas)
- Bile duct stones (stones in the bile duct)
- Cholecystitis (inflammation of the gallbladder)
- Bile duct malignancy (cancer in the bile duct)
- Peptic ulcer disease (sores in the stomach lining)
What to expect with Gallstone Ileus
Gallstone ileus is a serious disorder, usually occurring in individuals with multiple other medical conditions. High rates of illness and death have been reported in patients with gallstone ileus. Urgent surgical treatment often results in post-surgery complications. Moreover, the longer the surgery lasts, the higher the risk of complications after the operation. A one-time procedure has a higher risk of causing illness, but a two-stage procedure would require the patient to be put under general anesthesia again.
Possible Complications When Diagnosed with Gallstone Ileus
Some complications that may arise include blockage in the bowel, infection, and inflammation in the pancreas. Other possibilities are:
- Acute kidney failure
- Wound splitting open
- A connection forming between the gallbladder and the skin
- Bloodstream infection
- Infections in the urinary tract
- Leaks in the bowel connections
- Pus-filled pocket in the abdomen
- Death
Preventing Gallstone Ileus
If you have gallstone ileus, it’s very important that you understand your condition and stay in close contact with your healthcare providers. It’s crucial to know the common signs and symptoms of complications that might occur after your treatment, and to get medical attention right away if you notice these. You’d also be advised to keep a healthy weight by watching your diet and regularly exercising.