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Special Feature
June 1, 2006

Image of the Month—Diagnosis

Arch Surg. 2006;141(6):610. doi:10.1001/archsurg.141.6.610
Answer: Enterolithotomy

A midline laparotomy was performed, a dilated proximal small intestine was found, and a large gallstone was identified in the proximal jejunum with dilated bowel proximal to the point of impaction. An enterolithotomy was performed by making a longitudinal enterotomy proximal to point of the impaction, milking the gallstone proximally and removing it. Subsequently, the enterotomy was closed in a transverse fashion and the bowel was run to ensure that there were no other gallstones in the remainder of the small intestine. The abdomen was closed without performing cholecystectomy.

Gallstone ileus is a rare complication of cholelithiasis occurring in approximately 0.5% of patients. The average age of patients who develop gallstone ileus is 70 years, and women are affected 3 to 16 times more often than men. The gallstone ileus develops from pericholecystic inflammation after cholecystitis, which in turn leads to an adhesion between the biliary and enteric systems. Next, the pressure necrosis from the gallstone causes erosion into the bowel, creating a fistula. Most (60%) of the fistulas form between the gallbladder and the duodenum, but they can also be found within the stomach and the large bowel. The majority of stones that cause gallstone ileus are larger than 2 cm, and the impaction most often occurs in the ileum (70%), with other locations being the jejunum, stomach, and colon.1The impaction at the pylorus causing a gastric outlet obstruction is called Bourveret syndrome. At times, there is impaction in the colon with the presence of colonic pathologic abnormalities such as a polyp or cancer.

Gallstone ileus is seen most often in elderly women and usually presents with vague, intermittent abdominal pain and vomiting. Moreover, patients may have hematemesis with hemorrhage at the biliary enteric fistula. At times, patients also have cholecystitis, fever, abdominal distention, and jaundice. An abdominal radiograph may show partial or complete bowel obstruction (50% of patients), stone (<15% of patients), and pneumobilia (30%-60% of patients). An abdominal computed tomographic scan may help in confirming the diagnosis by showing the gallbladder thickening, pneumobilia, intestinal obstruction, and gallstone.2The standard treatment of gallstone ileus is enterolithotomy performed by longitudinal enterotomy proximal to the point of impaction, removal of the stone, then transverse closure of the enterotomy. It is very important to inspect the remainder of the bowel for the presence of additional stones. In the past, most patients also underwent cholecystectomy in addition to enterolithotomy, but this practice has been abandoned owing to a significant increase in mortality.3In conclusion, gallstone ileus occurs in elderly women with vague abdominal pain, vomiting, and a history of cholelithiasis. The treatment is surgical enterolithotomy alone.

Correspondence:Sareh Parangi, MD, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Stoneman 934, Boston, MA 02215 (sparangi@caregroup.harvard.edu).

Accepted for Publication:May 5, 2005.

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