Gallstone ileus

Mechanical small bowel obstruction by a gallstone (passed via a biliary-enteric fistula); a rare complication of chronic gallstone disease.

• Uncommon but deadly cause of bowel obstruction in older patients (≈20% mortality). Classic radiographic clues (Rigler's triad) make it a favorite on board exams.

• Older adult (usually female) with crampy abdominal pain, distension, and vomiting (signs of SBO).
• Often history of gallstones or cholecystitis, but no prior abdominal surgeries (no adhesion risk).
• Symptoms may wax and wane initially as the stone intermittently obstructs ("tumbling" obstruction).

1. Suspect gallstone ileus in an SBO case with no surgical history but risk factors for gallstones.
2. Look for pneumobilia (air in biliary tree) on imaging as a key clue; abdominal CT is the diagnostic test of choice.
3. Stabilize like any SBO (IV fluids, electrolyte correction, NG tube for decompression).
4. Urgent surgery is required to remove the stone and relieve the obstruction.

1. Stabilize first with IV fluids, correction of electrolytes, and NG tube decompression.
2. Then perform an enterolithotomy (open the intestine to remove the obstructing stone) to relieve the blockage.
3. Resect any bowel segment that is necrotic or perforated.
4. Cholecystectomy and fistula closure can be done later (two-stage) once patient is stable; one-stage surgery (stone removal + cholecystectomy/fistula repair in one operation) is considered in select cases but carries higher risk.

• Rigler's triad: SBO + pneumobilia + ectopic gallstone on imaging is pathognomonic for gallstone ileus.
• Despite the name, it's a mechanical obstruction (stone jam), not a true paralytic ileus.

• Signs of bowel ischemia (fever, peritonitis, lactic acidosis) in SBO → indicates strangulation/perforation, need emergent surgery (bowel resection likely).
• Persistent obstruction or recurrence after stone removal → suspect a second gallstone obstruction (look for another stone).

1. Older patient with SBO + gallstone history (no prior surgery) → suspect gallstone ileus.
2. Obtain abdominal CT: if Rigler's triad (SBO + pneumobilia + ectopic stone) → diagnosis confirmed.
3. Stabilize the patient (IV fluids, NG decompression, correct electrolytes).
4. Proceed to surgery for stone removal (enterolithotomy). Plan elective cholecystectomy/fistula repair later unless patient is stable enough for one-stage surgery.

• Elderly woman with no surgery history, presenting with SBO (abdominal pain, vomiting, distension) and known gallstones → think gallstone ileus.
• Abdominal X-ray or CT showing dilated small bowel loops, air in the biliary tree, and a radiopaque stone in the intestine (Rigler's triad) is diagnostic.