Gall Stone Ileus - Erler Zimmer

Gall Stone Ileus - Erler Zimmer

Clinical History

A 54-year-old man presented to the hospital with 12 hours of severe colicky pain, nausea, and vomiting. On history, he was noted to have had a 3-year history of intermittent right subcostal pain for which he had not seen a doctor. He was diagnosed as having an acute bowel obstruction, and a laparotomy was performed.

Pathology

This segment of the small bowel has been opened to display a large pigmented, ovoid gallstone with a roughened surface. This is an example of gallstone ileus.

Further Information

Gallstone disease is an uncommon cause of bowel obstruction, accounting for only 0.5% of cases, with a preponderance for older and female patients. It most commonly occurs secondary to biliary-enteric fistulae (which can be to proximal or distal portions of the bowel) but can also occur after sphincterotomy. Stones are usually over 2-2.5cm, and 70% impact in the ileum, while others obstruct at sites of stricture/narrowing. The history may include episodic obstructive symptoms. Diagnosis is confirmed either radiologically (often on a CT scan) or at the time of removal. Rigler’s triad is typical for gallstone ileus and consists of: (1) small bowel obstruction, (2) a gallstone outside the gallbladder, and (3) air in the bile ducts (pneumobilia) seen on imaging and gallstone presence on plane XR. Treatment usually involves surgery with the removal of the obstructing stone, closure of the fistula, and cholecystectomy to prevent recurrence. These procedures may need to be staged.