Hepatobiliary—Gallstone Ileus
Concept
Mechanical obstruction in the terminal ileum from a large gallstone that has eroded through the gallbladder into the duodenum. Seen in elderly patients with SBO who have no hernia and no previous surgeries.
Way Question May be Asked?
“A 74 y/o female is seen in the emergency department for a small bowel obstruction. Obstruction series confirms the small bowel obstruction with air in the biliary tree. What do you want to do?” May be given AXR with stone in the RLQ or air in the biliary tree or patient with episodes of SBO.
How to Answer?
H +P while resuscitating the pt
History
Prior surgery Malignancy history Overall medical condition
History suggestive of gallbladder disease History of intermittent obstruction classic
Physical Exam
Vital signs (pt may be unstable) Check for surgical scars Check for hernias!
Diagnostic Tests
Full lab panel (including LFTs—may be other stones)
Obstruction series
CT scan (not usually necessary)
Surgical Treatment
Resuscitate the pt, NGT, IVF, then:
OR for exploration:
Full ex lap (be prepared to describe this)
Check status of RUQ (extensive scarring prevents definitive procedure)
Enterotomy is performed proximal to palpable stone lodged in the terminal ileum
“Milk” stone back gently Close enterotomy in two layers
Check rest of intestine for additional stones (~5%) Attention to RUQ (mortality less in retrospective
series if done in separate procedures!)
→ takedown of fistula and closing the bowel in two layers, cholecystectomy and cholan- giogram (to look for other stones)
(only if inflammation not severe, pt is stable, and scarring will not preclude safe dissection)
Common Curveballs
Pt will have history of malignancy
Pt will have associated intraabdominal process
Pt will have severe scarring in RUQ precluding defini- tive procedure
Pt will have bowel obstruction post-op (missed a second stone)
Pt will be septic/unstable
Stone will have eroded through hepatic flexure of colon rather than duodenum
Being asked how to close the fistula
Gallbladder cancer that led to the perforation (change scenario)
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Pt will develop cholangitis or intraabdominal abscess post-op
Post-op biliary leak
Strikeouts
Not checking for hernias
Not getting obstruction series but skipping to CT scan
Not checking for prior surgeries Not recognizing the problem
Not “milking” back the stone but making enterotomy in terminal ileum
Performing takedown of fistula in unstable pt
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