Figure 1. Computed tomographic scan of the abdomen demonstrates the obstructing stone in the sigmoid colon.
Figure 2. Intraoperative sigmoid colon enterotomy and gallstone extraction.
Gallstone ileus accounts for only 1% to 3% of cases of intestinal obstruction, but the rate rises to 25% in patients older than 65 years.1 Meanwhile, intestinal obstruction is a complication in only 0.3% to 0.5% of all cases of cholelithiasis.2 Gallstone ileus with colonic obstruction is very rare, accounting for 2% to 8% of all cases of gallstone ileus since Courvoisiers' original article in 1890.3
Gallstone ileus is most commonly seen in conjunction with a cholecystoduodenal fistula but may be associated (in decreasing incidence) with cholecystogastric, cholecystocolic, and cholecystoduodenocolic fistulas.1 Elderly women in their sixth or seventh decade of life are most commonly affected. The incidence of concomitant disease with gallstone ileus is high, with many series reporting diabetes, cardiovascular disease, and morbid obesity in 50% to 60% of patients.2
Most patients with cholecystocolic fistulae exhibit vomiting, watery diarrhea, and abdominal pain. Bilious vomiting is characteristic of high obstruction, whereas feculent vomiting and abdominal distension are more prominent in ileal obstruction. Most cases of intestinal obstruction occur in the terminal ileum. In patients with incomplete bowel obstruction, the symptoms are intermittent, as the stone lodges at various levels, characterized as "tumbling obstruction."2 Physical examination may indicate abdominal distension, muscle guarding, dehydration, and the presence of concurrent disease. Jaundice is uncommon.2 Laboratory studies are usually nonspecific but reflect dehydration and electrolyte imbalance due to intestinal obstruction.2
A fistula forms when the gallbladder ruptures into one of the surrounding adherent viscera or when a large gallstone causes pressure necrosis of the gallbladder wall, leading to perforation. Under these circumstances, gallstones that exceed 2.5 cm may cause large-bowel obstruction most commonly at the sigmoid colon, where there is often underlying diverticular disease.3
The signs of gallstone ileus on plain abdominal radiography are (1) pneumobilia or air in the bilary tree (75% of cases); (2) evidence of partial or complete intestinal obstruction; and (3) with the aid of contrast media, direct or indirect evidence of an obstructing stone in the intestine.2 Contrast imaging is essential for delineating the fistulous connections and locating the level of obstruction. Computed tomographic imaging may show pneumobilia and gallstone impaction at the point of obstruction (Figure 1).
Gallstone ileus requires emergency enterolithotomy (Figure 2) to relieve the obstruction. However, concomitant surgery to the cholecystocolic fistula is discouraged on the basis that subsequent symptoms of weight loss, malabsorption, and cholangitis are rare. Furthermore, a minimalist approach is recommended in these patients, who are often elderly and debilitated.2
Recurrent obstruction occurs in 3% to 5% of cases, prompting consideration of single-stage cholelithotomy, cholecystectomy, and exteriorization of the fistula as a diverting colostomy.4 However, relief of obstruction should be the primary goal, leaving definitive fistula surgery for the elective setting, where the morbidity of the disease must be weighed against the hazards of surgical repair.3
Corresponding author: Gerrard O'Donoghue, AFRCSI, Department of Surgical Research, Education and Research Centre, Beaumont Hospital, Dublin 9, Ireland (e-mail: firstname.lastname@example.org).
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
Thank you for submitting a comment on this article. It will be reviewed by JAMA Surgery editors. You will be notified when your comment has been published. Comments should not exceed 500 words of text and 10 references.
Do not submit personal medical questions or information that could identify a specific patient, questions about a particular case, or general inquiries to an author. Only content that has not been published, posted, or submitted elsewhere should be submitted. By submitting this Comment, you and any coauthors transfer copyright to the journal if your Comment is posted.
* = Required Field
Disclosure of Any Conflicts of Interest*
Indicate all relevant conflicts of interest of each author below, including all relevant financial interests, activities, and relationships within the past 3 years including, but not limited to, employment, affiliation, grants or funding, consultancies, honoraria or payment, speakers’ bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued. If all authors have none, check "No potential conflicts or relevant financial interests" in the box below. Please also indicate any funding received in support of this work. The information will be posted with your response.
Register and get free email Table of Contents alerts, saved searches, PowerPoint downloads, CME quizzes, and more
Subscribe for full-text access to content from 1998 forward and a host of useful features
Activate your current subscription (AMA members and current subscribers)
Purchase Online Access to this article for 24 hours
Some tools below are only available to our subscribers or users with an online account.
Download citation file:
Web of Science® Times Cited: 4
Customize your page view by dragging & repositioning the boxes below.
and access these and other features:
Enter your username and email address. We'll send you a link to reset your password.
Enter your username and email address. We'll send instructions on how to reset your password to the email address we have on record.
Athens and Shibboleth are access management services that provide single sign-on to protected resources. They replace the multiple user names and passwords necessary to access subscription-based content with a single user name and password that can be entered once per session. It operates independently of a user's location or IP address. If your institution uses Athens or Shibboleth authentication, please contact your site administrator to receive your user name and password.