Gallstone ileus. Clinical contribution

Gallstone ileus, responsible for 1-3% of intestinal obstructions, is usually secondary to a cholecysto-duodenal fistula with subsequent migration of a stone in the intestinal lumen. In 70% of cases the calculus, if larger than 2.5 cm, stops at the ileocecal valve; in the remaining cases it stalls at the duodenum, jejunum or descending colon. The authors report their recent experience regarding 3 patients with gallstone ileus; 2 of these patients during the days preceding the admission at the hospital, suffered of subocclusive episodes interrupted by periods of wellness. Plain abdominal X-rays showed air fluid levels, but not aerobilia nor ectopic calculus, as described by Rigler, probably because of the small size of the fistula and the radiotransparency of the stone. In a patient, a preoperative CT scan was done, showing a stone at ileocecal valve. Nowadays, for diagnostic purposes, also ultrasound, X-rays with contrast and colonscopy are utilized. Our 3 patients underwent a simple enterolithotomy, without repair of the fistula, because of firm phlogistic adhesions in the epatoduodenal space together with associated diseases which could preclude the good outcome of the operation. Possible complications of this procedure are recurrence of gallstone ileus, cholangitis and development of a carcinoma of the gallbladder. The combined procedure (enterolithotomy, cholecystectomy and repair of the fistula) is indicated in presence of biliary leakage, abscesses or gangrene of the gallbladder. Recently, other treatments, besides laparoscopy, were described, as extracorporeal lithotripsy and hydraulic lithotripsy, with encouraging results, though these techniques may not be carried out in all patients.