Imaging leads to a prompt Dx
In a patient with gallstone ileus, imaging studies typically show a classic radiographic triad (Rigler’s triad) consisting of small bowel obstruction, pneumobilia, and an ectopic gallstone.2,5 Optimizing patient management hinges on prompt correction of fluid and electrolyte imbalances and surgical intervention.
Surgical management of gallstone ileus must be individualized according to the patient’s comorbid conditions.6 Patients with significant comorbidities are usually managed with a 2-stage procedure: first with enterolithotomy to relieve the obstruction, and later with biliary tract surgery.7 This approach avoids the need for fistula exploration and reduces operative time. (Most fistulas close spontaneously if left alone.) Performing enterolithotomy and biliary tract surgery at the same time (a one-stage procedure) is more technically difficult, but reduces the risk of recurrent gallstone ileus or cholecystitis. Published reports show a lower mortality rate for the 2-stage procedure (11%) compared to the one-stage procedure (16.7%).7
After fluid resuscitation, our patient underwent an exploratory laparotomy, during which a 2.5 x 1.5 cm stone was extracted from the ileum. A cholecystoduodenal fistula was left intact because the chances of recurrence are very low and the patient did not have residual gallstones. Fistula repair is usually done 6 to 8 weeks after resolution of acute symptoms, but a less aggressive surgical approach was used for our patient. The patient remained well on follow-up at 6 months.
CORRESPONDENCE
Chhavi Kaushik, MD, Thomas Jefferson University Hospital, 132 S. 10th Street, Philadelphia, PA 19107; ckaushik.ck@gmail.com