Report of two cases of gallstone ileus and literature review

Background

Gallstone ileus is a rare but potentially serious complication of cholelithiasis, prevailing in female elderly patients in whom it represent the third cause of mechanical bowel obstruction. Debate currently exists regarding the appropriate surgical strategy. We report two cases of gallstone ileus and review of the literature.

Materials and methods

Two female elderly patients (83 and 87 years old) recently came to our attention for a mechanical bowel obstruction. Their routine blood investigation revealed only high urea, creatinine and phosphates. Ultrasonography showed scleroatrophic lithiasic cholecistytis. The abdominal X-ray didn't show any sign of Rigler's triad, except for small bowel obstruction. Laparotomy displayed scleroatrophic lithiasic gallbladder firmly adherent to the second portion of duodenum with intense surrounding inflammation due to cholecystoduodenal fistula. Also a gallstone, measuring approximately 3 × 2 cm (case 1) and 6 × 5 cm (case 2), was found impacting the ileum. The surgical strategy, chosen according to the clinical status of these patients (ASA3) and the difficult identification of Calot's triangle, consisted in performing an enterolithotomy and cholecystostomy through a Petzer catheter, after removing multiple gallstones and biliary sludge.

Results

In postoperative course it was only observed, in case 2, slight temperature and neutrophil leukocytosis, solved in few days without complications. Drainage removal in 10^th p.o. day (case 1) and in 12^th p.o. day (case 2); Discharge was in 12^th and 15^th p.o. day respectively; Petzer catheter was removed two months later after ultrasonographic and cholecystographic evaluation.

Presently the patients are in good health without any biliary signs and symptoms.

Conclusion

The diagnosis of gallstone ileus is difficult, in 50% of cases it is often made at laparotomy. Choice of surgical procedure must be determined by the clinical condition of the patient and by intraoperative evaluation. Doko et al agreed that the one-stage procedure should be reserved only for highly selected patients with absolute indications. Enterolithotomy alone is the elective surgical option in unstable elderly patients (mortality rate of 11.7% vs 16.9% for the one-stage procedure) and subsequent cholecystectomy is not mandatory. Recently, laparoscopy-guided enterolithotomy has become the preferred surgical approach in treating gallstone ileus. Cholecystostomy with enterolithotomy might be an adequate treatment, in selected cases, for reducing the risk of early re-operation due to biliary pathology recurrence. Potential cholecistectomy and fistula closure would be performed only after a complete patient stabilization.