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Gallstone ileus


Andrew P Keaveny, MD
Nezam H Afdhal, MD


UpToDate performs a continuous review of over 330 journals and other resources. Updates are added as important new information is published. The literature review for version 13.1 is current through December 2004; this topic was last changed on January 4, 2005. The next version of UpToDate (13.2) will be released in June 2005.

Gallstone ileus is an important, though infrequent cause of mechanical bowel obstruction, affecting elderly patients who often have other significant medical conditions. It is caused by impaction of a gallstone in the ileum after being passed through a biliary-enteric fistula. The diagnosis is often delayed since symptoms may be intermittent and investigations fail to identify the cause of the obstruction. The mainstay of treatment is removal of the obstructing stone after resuscitating the patient. Gallstone ileus continues to be associated with relatively high rates of morbidity and mortality.

INCIDENCE — Gallstone ileus is an unusual complication of cholelithiasis, occurring in less than 0.5 percent of patients. It is responsible for approximately 1 to 4 percent of all cases of mechanical obstruction and, in patients over age 65, accounts for 25 percent of nonstrangulated small bowel obstruction [1]. Thus, gallstone ileus should always be in the differential diagnosis when assessing an elderly person with intestinal obstruction.

The average age of patients with gallstone ileus is 70 years, with the youngest reported subject being 13 years of age. There is a distinct female predominance, occurring 3 to 16 times more commonly in females than in males [2].

PATHOGENESIS — The usual means of gallstone entry into the bowel is through a biliary enteric fistula, which complicates 2 to 3 percent of all cases of cholelithiasis with associated episodes of cholecystitis. Sixty percent are cholecystoduodenal fistulas, but cholecystocolonic and cholecystogastric fistulas can also result in gallstone ileus [3]. (See "Clinical features and diagnosis of acute cholecystitis").

The following sequence is responsible for most cases of fistula formation. Pericholecystic inflammation after cholecystitis leads to the development of adhesions between the biliary and enteric systems. Pressure necrosis by the gallstone against the biliary wall then causes erosion and fistula formation. In addition, two cases of gallstone ileus have occurred after endoscopic sphincterotomy. In this setting, the stone is presumed to have passed into the small bowel through the sphincterotomy and to have been large enough to cause obstruction [4]. Gallstone ileus is also a rare complication of Crohn's disease.

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