Published online Jun 16, 2023. doi: 10.12998/wjcc.v11.i17.4159
Peer-review started: March 22, 2023
First decision: April 11, 2023
Accepted: May 9, 2023
Article in press: May 9, 2023
Published online: June 16, 2023
Gallstone ileus is a rare complication of gallstone disease in which a stone enters the enteric lumen and causes mechanical obstruction usually by bilioenteric fistula. Gallstone ileus accounts for 25% of all bowel obstructions among the population > 65 years of age. Despite medical advances over the last decades, gallstone ileus is still associated with high rates of morbidity and mortality.
An 89-year-old man with a history of gallstones was admitted to the Gastroenterology Department of our hospital, complaining of vomiting and cessation of bowel movements and flatus. Abdominal computed tomography showed cholecystoduodenal fistula and upper jejunum obstruction due to gallstones, pneumatosis in the gallbladder, and pneumobilia indicating Rigler’s triad. Considering the high risk of surgical management, we performed propulsive enteroscopy and laser lithotripsy twice to relieve the bowel occlusion. However, the intestinal obstruction was not relieved by the less invasive procedure. Then, the patient was transferred to the Department of Biliary-pancreatic Surgery. The patient underwent the one-stage procedure including laparoscopic duodenoplasty (fistula closure), cholecystectomy, enterolithotomy, and repair. After surgery, the patient presented with complications of acute renal failure, postoperative leak, acute diffuse peritonitis, septicopyemia, septic shock, and multiple organ failure, and finally died.
Early surgical intervention is the mainstay of treatment for gallstone ileus. For elderly patients with significant comorbidities, enterolithotomy alone is advised.
Core Tip: Gallstone ileus is a rare complication of gallstone disease that is common in elderly patients, with high mortality. In this case of gallstone ileus, abdominal imaging showed classical Rigler’s triad including ectopic gallstone, intestinal obstruction, and pneumobilia. We performed propulsive enteroscopy and laser lithotripsy twice but failed to remove the stone. Finally, the patient underwent the one-stage procedure including laparoscopic duodenoplasty (fistula closure), cholecystectomy, and enterolithotomy. However, the patient presented with several complications including acute renal failure and finally died. Early surgical intervention is the main treatment for gallstone ileus. For elderly patients with significant comorbidities, enterolithotomy alone is advised.