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Difficulty: MediumGastrointestinal and Abdominal Surgery

An 82-year-old woman is brought to the emergency department from a skilled nursing facility due to a 3-day history of progressive abdominal distension, colicky abdominal pain, and intractable vomiting. The nursing facility staff reports that her vomit has a dark green, bilious appearance and she has not had a bowel movement or passed flatus for the last 4 days. Her medical history is significant for moderate dementia, hypertension, and recurrent episodes of postprandial right upper quadrant pain for which she previously declined surgical intervention.

Vital signs are:
Temperature: 37.4°C (99.3°F)
Heart rate: 105/min
Blood pressure: 110/70 mm Hg
Respiratory rate: 18/min

Physical examination reveals a markedly distended abdomen with high-pitched, hyperactive bowel sounds. There is mild, diffuse tenderness to palpation, but no guarding, rigidity, or rebound tenderness. Laboratory studies show a leukocyte count of 11,000/mm³ and mild hypokalemia.

A computed tomography (CT) scan of the abdomen and pelvis reveals dilated loops of small bowel with a distinct transition point in the right lower quadrant, air within the biliary tree, and a 3-cm radio-opaque, calcified mass impacted in the terminal ileum.

Which of the following is the most appropriate next step in management?

  1. Exploratory laparotomy with enterolithotomyAnswer
  2. B
    Endoscopic retrograde cholangiopancreatography
  3. C
    Exploratory laparotomy with concurrent cholecystectomy and fistula repair
  4. D
    Nasogastric tube decompression, intravenous fluids, and clinical observation
  5. E
    Percutaneous cholecystostomy tube placement

Answer

Exploratory laparotomy with enterolithotomy
The correct approach for gallstone ileus is an exploratory laparotomy with enterolithotomy alone. The primary surgical goal is to relieve the mechanical small bowel obstruction by extracting the impacted gallstone, typically found at the terminal ileum. Because gallstone ileus predominantly affects elderly, frail patients, minimizing the surgical footprint is critical. A more extensive one-stage procedure (involving enterolithotomy, cholecystectomy, and closure of the cholecystoenteric fistula) is associated with significantly higher morbidity and mortality and should be avoided in the acute setting.

Step-by-Step Solution

1
Analyze the clinical presentation and imaging findings.
The patient presents with signs and symptoms of a small bowel obstruction (SBO), including bilious vomiting, abdominal distension, obstipation, and hyperactive bowel sounds. The CT scan reveals the Rigler triad: pneumobilia, SBO, and an ectopic gallstone in the terminal ileum.
Identifying the classic triad confirms the diagnosis of gallstone ileus.
2
Determine the optimal management strategy for gallstone ileus.
Gallstone ileus requires surgical extraction of the impacted stone (enterolithotomy) to relieve the mechanical obstruction.
Large gallstones that cause ileus rarely pass spontaneously. Delaying surgery can lead to bowel necrosis.
3
Consider whether concurrent biliary surgery is indicated.
Concurrent cholecystectomy and fistula repair should be avoided.
A one-stage procedure carries a high mortality rate in elderly patients. The safest approach is a simple enterolithotomy, reserving definitive biliary surgery for patients who later develop recurrent biliary symptoms.

Key Concept

Gallstone ileus is a mechanical small bowel obstruction managed acutely with a simple enterolithotomy; concurrent cholecystectomy and fistula repair are generally avoided due to high mortality rates in this predominantly elderly patient population.
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Topics

Gastrointestinal and Abdominal Surgery

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