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Difficulty: MediumGastrointestinal and Abdominal Surgery

An 80-year-old female is evaluated in the surgical assessment unit for a 3-day history of intermittent, crampy abdominal pain and progressive nausea with bilious vomiting. She has a history of hypertension, type 2 diabetes mellitus, and symptomatic gallstones for which she declined surgery two years ago. Her temperature is 37.8°C (100.0°F), blood pressure is 112/68 mm Hg, and pulse is 95/min. On physical examination, the abdomen is distended and tympanitic to percussion, with high-pitched bowel sounds. There is mild, diffuse abdominal tenderness but no rebound or guarding. Laboratory studies show a leukocyte count of 11,200/mm³ and a normal serum amylase level. A plain abdominal radiograph reveals multiple dilated loops of small intestine with air-fluid levels, an absence of colonic gas, and branching radiolucencies over the central hepatic shadow. Which of the following is the most appropriate next step in the management of this patient?

  1. Emergency surgical enterolithotomyAnswer
  2. B
    Nasogastric decompression and clinical observation
  3. C
    Single-stage enterolithotomy, cholecystectomy, and fistula repair
  4. D
    Endoscopic retrograde cholangiopancreatography
  5. E
    Ultrasound-guided percutaneous cholecystostomy

Answer

Emergency surgical enterolithotomy
The patient's clinical and radiographic presentation is classic for gallstone ileus. This condition occurs when a large gallstone erodes through the gallbladder wall into the small intestine (usually the duodenum), creating a cholecystoenteric fistula. The stone travels distally and impacts at the narrowest portion of the bowel, most commonly the terminal ileum, causing a mechanical small bowel obstruction (SBO). The presence of 'branching radiolucencies over the central hepatic shadow' indicates air in the biliary tree (pneumobilia). Pneumobilia, clinical SBO, and an ectopic radiopaque gallstone constitute Rigler triad. The definitive management is an emergency surgical enterolithotomy (an incision into the intestine to extract the stone).

Step-by-Step Solution

1
Analyze the clinical presentation.
The patient has signs and symptoms of a mechanical small bowel obstruction (SBO), including crampy pain, bilious vomiting, and a distended abdomen with air-fluid levels.
Identifying the primary physiological derangement (SBO) dictates the urgency and direction of management.
2
Interpret the specific imaging findings.
The radiograph shows pneumobilia (branching radiolucencies over the liver) in the setting of an SBO.
The combination of SBO, pneumobilia, and an ectopic gallstone is known as Rigler triad, which is pathognomonic for gallstone ileus.
3
Determine the optimal surgical approach.
The patient requires an emergency enterolithotomy to remove the impacted stone from the small bowel.
Extracting the stone relieves the obstruction with the lowest mortality. Complex concurrent biliary procedures are contraindicated in the acute setting for elderly patients.

Key Concept

Gallstone ileus classically presents with signs of small bowel obstruction and pneumobilia on imaging; the standard of care is an emergency surgical enterolithotomy alone.
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Topics

Gastrointestinal and Abdominal Surgery

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