Answers

Short answers

1. The arrows in figure 1 show pneumobilia (air in the biliary tree), a common finding after an intervention in the biliary tract or in patients with gallstone ileus.

2. The arrowheads in figure 1 indicate a massive gallstone located in the proximal jejunum.

3. A gallstone may enter the gastrointestinal tract via a fistula between the (gangrenous) gallbladder and the intestine, where it can cause an ileus.

4. Gallstone ileus is an indication for immediate surgery. Surgical options include enterolithotomy, cholecystectomy, and fistula division, with or without common bile duct exploration (one stage procedure), or initial enterolithotomy only, with definitive repair performed at a second operation (two stage procedure).

Long answers
Pneumobilia
Conventional abdominal radiography shows pneumobilia—air in the biliary tree (fig 1), which was confirmed by abdominal ultrasonography. This is a common finding after an intervention in the biliary tract or in patients with gallstone ileus.

Gallstone
Subsequent computed tomography showed that the ileus and pneumobilia were caused by an intraluminal concretion with a diameter of 3.2 cm in the proximal jejunum (fig 2 ). This concretion can be seen on the conventional abdominal x ray (fig 1, arrowheads). A fistula was present between gallbladder and duodenum.

View larger version (62K): [in this window] [in a new window] [PowerPoint Slide for Teaching]   Arrow indicates an intraluminal concretion with a diameter of 3.2 cm

 
Explaining the patient’s symptoms
One or more gallstones may enter the gastrointestinal tract via a fistula between the (gangrenous) gallbladder and the intestine, where it may cause an ileus. Occasionally, a stone may enter through a fistulous communication originating from the common bile duct. In the West, gallstones cause up to a quarter of small bowel obstructions.^{1 2} Gallstone ileus is more common in females than in males (ratio 3.5:1), and the most common locations of impaction of gallstone are the terminal ileum and the ileocaecalvalve because of the anatomical small diameter and less active peristalsis.² Less common locations for impaction are the jejunum, the ligament of Treitz, and the stomach; impaction is rare in the duodenum and colon. The location in our patient, the proximal jejunum, might be related to the large size of the gallstone (3.2 cm) impeding its progression. About half of cases of gallstone ileus may include symptomatic cholelithiasis.²

Management
Although gallstone ileus is an indication for immediate surgery, the patient’s condition should be stabilised by fluid or electrolyte supplementation before surgery.³ Surgical options include enterolithotomy, cholecystectomy, and fistula division, with or without common bile duct exploration (one stage procedure), or definitive repair performed at a second operation (two stage procedure). In patients with a low operative risk, a one stage procedure is recommended.

Alternatively, after initial enterolithotomy, an elective laparoscopic cholecystectomy can be considered in patients with symptoms or residual cholelithiasis (if the risk for further surgery is acceptable). In the past decade, laparoscopy guided enterolithotomy has been used to treat gallstone ileus.⁴ In general, a mini-laparotomy will be performed.

As our patient was haemodynamically stable, the gallstone could be removed on the same day by mini-laparotomy. Because of the increased risk (the patient’s age), we decided not to explore the biliary tract or perform cholecystectomy. The patient left the hospital a few days later without any symptoms.

In patients with symptoms of ileus, especially if conventional radiography shows pneumobilia, gallstone ileus should be considered.

Cite this as: BMJ 2009;338:b425