Computed tomographic scans revealed a mechanical ileus with a distended jejunum and proximal ileum. In particular, a cockade in the distal small bowel and a large diverticulum of the duodenum were depicted on computed tomographic scans. The patient was taken to the operating room and a short median laparotomy was performed. The origin of the mechanical ileus was a large gallstone (45 × 25 × 20 mm) 70 cm distal to the ligament of Treitz. Segmental bowel resection was performed. The patient was discharged a few days later after an uneventful recovery.
This case describes a gallstone ileus in the absence of the gallbladder. The site of stone formation was probably a large diverticulum of the duodenum. This duodenal diverticulum most likely originated from the base of the distal common bile duct next to the head of the pancreas (Figure 2). Stone formation in the common bile duct seems unlikely in light of the volume of the gallstone and unremarkable biliary tract.
Paracoronal reconstructions of the computed tomographic scan showing the duodenal diverticulum (asterisk) at the base of the distal common bile duct (arrow) next to the head of the pancreas (arrowhead).
Gallstone ileus is a rare disease that typically occurs in elderly individuals and is associated with high mortality rates up to 18%.1,2 Intraluminal impaction of gallstones in the intestinal tract usually occurs as a result of recurrent cholecystitis leading to penetration of a gallstone through a biliodigestive fistula. In 15% to 20% of cases, the gallstones reach the intestinal tract in a natural way.3 The most common site of stone impaction is the terminal ileum and ileocecal valve and, to a lesser extent, in the jejunum and stomach, while the duodenum and colon are rare locations.2,4,5 Stone impaction at the colon may take place because of a concomitant obstructive disease and a cholecystocolonic fistula.6,7
Plain abdominal radiographs are diagnostic for gallstone ileus in about 50% of the cases.5 Abdominal computed tomography is preferable in identifying a gallstone ileus because of its good sensitivity and specificity. Detection of the specific site and size of the impacted stone and direct visualization of the biliodigestive fistula is possible.8
Surgery is the treatment of choice, with 2 possible approaches: enterolithotomy alone through laparotomy or laparoscopy, which is advised especially in elderly patients with associated comorbidities.9 The 1-stage procedure on the other side includes enterolithotomy, cholecystectomy, and fistula repair and offers a definitive management in avoiding another operation but is accompanied by higher mortality rates. There is no consensus on the choice of operation.5
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Correspondence: Guido Beldi, MD, Department of Surgery, Division of Visceral Surgery and Transplantation, University Hospital Bern, CH-3010 Bern, Switzerland (firstname.lastname@example.org).
Accepted for Publication: March 15, 2010.
Author Contributions: Dr Kaderli had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Kaderli, Fahrner, and Beldi. Acquisition of data: Kaderli and Beldi. Analysis and interpretation of data: Kaderli, Fahrner, Beldi, Patak, and Candinas. Drafting of the manuscript: Kaderli and Beldi. Critical revision of the manuscript for important intellectual content: Kaderli, Fahrner, Beldi, Patak, and Candinas. Administrative, technical, and material support: Fahrner and Patak. Study supervision: Beldi and Candinas.
Financial Disclosure: None reported.
Image of the Month—Diagnosis. Arch Surg. 2011;146(6):760. doi:10.1001/archsurg.2011.140-b