Gastric outlet obstruction caused by a large gallstone
blocking the pylorus or duodenum.
Unknown; fewer than 200 cases reported.
Acute cholecystitis results in adhesion formation
between the gallbladder and intestine. The large gallstone causes ischemia
of the cystic wall. Necrosis results, allowing passage of the stone through a
cholecystenteric fistula to any adherent bowel but, in more than 66% of
the cases, to the duodenum. However, duodenal obstruction constitutes only
3% of all cases of gall-stone ileus.
Usually made during operation but more recently at
endoscopy or on CT scan. The diagnosis is supported by air in the biliary tree
in the presence of a gastric outlet obstruction.
History of cholecystitis is present in
approximately half of patients. Signs and symptoms are those of small bowel
obstruction, nausea, vomiting, epigastric pain, and abdominal distension. Only 50 to
70% of patients present with the characteristic features of intestinal
obstruction, which may result from continuous impacting and disimpacting of
the stone during its passage distally. Relief of symptoms after the stone
becomes mobile again may suggest gastroenteritis, especially with the common
finding of diarrhea. However, as the diameter of the small bowel becomes
smaller distally and the gallstone bigger by accumulation of intestinal
contents, the impaction finally is complete and irreversible. Approximately
66% of all impacted gallstones are found in the ileum; only approximately
4% successfully pass the ileocecal valve and cause colonic obstruction.
Gastrointestinal hemorrhage may occur from duodenal ulceration or erosion of
cystic artery (one case). Vomiting leads to dehydration and electrolyte
disturbances (hypochloremic, hypokalemic metabolic alkalosis). Anemia may be
present as a consequence of occult loss or gastrointestinal hemorrhage.
Check volume status and correct hypovolemia,
hemoglobin, electrolytes, and acid-base status preoperatively. Investigate
coexisting diseases as indicated. Pass a nasogastric tube, which can be
removed for induction, to decompress the stomach.
Ileus and full stomach. Aspirate
nasogastric tube prior to rapid sequence induction. High abdominal incision
in patients with preexisting lung disease predisposes to postoperative
pulmonary complications; thoracic epidural analgesia may be advantageous.
Consider other therapeutic options, such as endoscopic stone removal,
endoluminal YAG-laser lithotripsy, or extracorporal shockwave lithotripsy.
No known specific implications.
Lobo DN, Jobling JC, Balfour TW. Gallstone ileus: Diagnostic pitfalls and
therapeutic successes. J Clin Gastroenterol
Swift SE, Spencer JA. Gallstone ileus: CT findings. Clin Radiol
Maiss J, Hochberger J, Hahn EG, et al: Successful laserlithotripsy in Bouveret's syndrome
using a new frequency doubled doublepulse Nd: YAG laser (FREDDY). Scand J Gastroenterol