Gallstone ileus

Gallstones are hard stones found in the gallbladder, and gallstone ileus is when a gallstone becomes lodged in the small bowel.

Risk factors for developing gallstones include things like female sex, obesity, pregnancy, and age, sometimes remembered by the 4 F’s—female, fat, fertile, and forty.

Sometimes those gallstones can get lodged in the cystic duct for long periods of time, and in that case, the bile inside the gallbladder tends to stagnate, and since the blockage doesn’t allow it to be squeezed out periodically to help with digestion, that stagnant bile which tends to irritate the gallbladder mucosa in the walls, and causes it to start secreting mucus and inflammatory enzymes, which results in some inflammation, distention and pressure build up—a condition known as cholecystitis, or inflammation of the gallbladder.

If the gallstone dislodges, the inflammation can clear up. On rare occasion, a large stone (typically over two and a half centimeters) can cause ongoing or repeated inflammation of the gallbladder, which can make the wall of the gallbladder a bit edematous or swollen and slightly more sticky.

As a result, the gallbladder wall can actually adhere to a nearby structure, most commonly at the duodenum, but occasionally to the stomach, colon, and jejunum.

Eventually these repeated bouts of inflammation might cause the gallbladder wall to thin out and erode away completely, forming a fistula—which is essentially a passageway between the gall bladder and the organ that it’s stuck to.

If the other organ is the small intestine, then this is called a cholecystoenteric fistula, and the fistula becomes a direct route for gallstones to enter the bowel.

Small gallstones might pass without any complication and leave the body along with the stool, but larger stones can get stuck along the GI tract, most commonly at the terminal ileum or the ileocaecal valve, causing mechanical obstruction, which can develop into a partial or complete obstruction.

Signs and symptoms of gallstone ileus include abdominal distension from the blockage, as well as nausea and vomiting, and a history of recurrent right upper quadrant pain, which is consistent with the repeated inflammation of chronic cholecystitis.

Individuals might also present with dehydration because a backup of fluid and air in the intestines can make a person feel a fairly strong aversion to food and drink.

Diagnosis can be confirmed via radiograph, looking for the characteristic Rigler’s triad: pneumobilia, or air in the bile ducts, evidence of a small bowel obstruction, and a gallstone outside the gallbladder.

Treatment typically involves managing symptoms like for example managing dehydration with intravenous fluids, and might involve nasogastric suctioning, which is inserting a tube through the nose to the GI tract, to remove fluid and air in order to relieve abdominal pressure that can build up when there is a bowel obstruction.

Finally, if there is a mechanical obstruction from a gallstone, then it might require emergency surgery. Alright, as a quick recap: gallstone ileus is where repeated cholecystitis, or inflammation of the gallbladder, cause a cholecystoenteric fistula to form, allowing gallstones to travel to the small bowel and become lodged, which can lead to mechanical obstruction.

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