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Gallstone ileus

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High Yield Notes

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Gallstone ileus

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Questions

USMLE® Step 1 style questions USMLE

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A 72-year-old woman comes to the emergency department because of intermittent crampy abdominal pain associated with nausea and vomiting for the last five days. She had an episode of vomiting with hematemesis six hours ago. Past medical history is significant for diabetes mellitus, gallstones, and hypertension. Current medications are metformin and lisinopril. Temperature is 38.2°C (100.8°F), pulse is 118/min, respirations are 22/min, and blood pressure is 110/60 mm Hg. Abdominal examination shows distention and tenderness, and hyperactive high-pitched bowel sounds are heard on auscultation. An abdominal radiograph shows pneumobilia and dilated loops of small bowel. Laboratory results are shown below:  
 
 Laboratory value Result 
Leukocyte count  23,250/mm3 
 Hemoglobin  12 g/dL 
 Hematocrit  46% 
 Platelets  400,000/µL 
 Lipase  140 U/L 
 AST, SGOT  47 U/L 
 ALT, SGPT  45 U/L 
 Total bilirubin  0.8 mg/dL 
Which of the following is the most likely underlying cause of this patient's presentation? 

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External References

First Aid

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Gallstone ileus p. 403

Ileus p. 393

bacterial peritonitis (spontaneous) p. 397

gallstone p. 403

Neurogenic ileus p. 239

Paralytic ileus p. 444

Postoperative ileus p. 239

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Content Reviewers

Rishi Desai, MD, MPH

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.