Radiology case: Gallstone ileus

 
Figure 1

Click “read the rest of the entry” below to see more images and more information.


Figure 2

Findings in this case: Figure 1. Coronal reconstruction of a CT study with contrast demonstrating a calcification impacted at the ileocecal valve (arrow). Figure 2. There is a gallstone in the dependent portion of the gallbladder (arrow). The gallbladder is distended. In this patient, the gallbladder is relatively normal on these images otherwise. 

Diagnosis: Gallstone ileus. 

Etiology, incidence and clinical information: 1) Gallstone ileus is actually a misnomer. It is an uncommon or rare cause of bowel obstruction secondary to impaction of a gallstone within the distal small bowel or at the ileocecal valve. 2) Estimates are that this is a cause of bowel obstruction and less than 5% of patients with bowel obstruction; however, in older patients some literature states that this may account for obstruction in up to 25% of bowel obstructions. The typical age is greater than 60-70 years of age. 

Diagnosis: 1) Due to the fact that there is impaction, the symptoms of bowel obstruction may be intermittent as a gallstone ultimately impacts and obstructs the small bowel and becomes disimpacted allowing small bowel contents through the area. 2) RIGHT upper quadrant pain is typically present in addition to symptoms of bowel obstruction. 3) Radiology: Classically, there is a triad (Rigler’s triad) of findings on CT = pneumobilia, small bowel obstruction and finding of an impacted gallstone in the distal small bowel or ileocecal valve. In this case, there was no evidence of pneumobilia; a) Plain films: Typically gallstones are not visible on plain films, however evidence of a bowel obstruction should be present; b) CT: Rigler’s triad may be evident. It should be noted that only calcified gallstones or gallstones with central air present are able to be demonstrated CT; c) Ultrasound: Evidence of gallstones and/or a thickened irregular gallbladder are typically present. There may be demonstrated within the gallbladder as foci of increased echogenicity. 

Prognosis: 1) Because of patient age, other associated illnesses, and risks associated with surgery typically seen in this age range of patients the morbidity and mortality can be very high with mortality reaching 15-20%. Treatment: Decompression of the bowel via nasogastric tube. If necessary, treatment of the gallbladder disease should be performed after the patient’s symptoms are under control and when the patient’s health and risk factors can be evaluated and improved to the best extent possible. Removal of the stone from the GI tract may or may not be necessary; however, stones which are less than 2.5 cm frequently pass given time. 

References:
Gallstone ileus
http://www.patient.co.uk/doctor/Gallstone-Ileus.htm 

Gallstone ileus http://www.learningradiology.com/archives05/COW%20150-Gallstone%20Ileus/gallstoneileuscorrect.htm 
CT in the Evaluation of Nontraumatic Abdominal Pain in Pregnant Women Radiology September 2007 244:3 784-790; doi:10.1148/radiol.2443061634 
Abstract http://radiology.rsna.org/content/244/3/784.abstract?sid=ed6f7b50-4693-4d96-8ad6-875338b3e537
Full Text http://radiology.rsna.org/content/244/3/784.full?sid=ed6f7b50-4693-4d96-8ad6-875338b3e537 
Full Text (PDF) http://radiology.rsna.org/content/244/3/784.full.pdf+html?sid=ed6f7b50-4693-4d96-8ad6-875338b3e537 
Figures Only http://radiology.rsna.org/content/244/3/784.figures-only?sid=ed6f7b50-4693-4d96-8ad6-875338b3e537 

Foreign Objects Encountered in the Abdominal Cavity at CT Radiographics March-April 2011 31:2 409-428; doi:10.1148/rg.312105123

Pattern Approach for Diseases of Mesenteric Small Bowel on Barium Studies Radiology November 2008 249:2 445-460; Published online September 23, 2008, doi:10.1148/radiol.2491071336
Abstract    http://radiology.rsna.org/content/249/2/445.abstract?sid=ed6f7b50-4693-4d96-8ad6-875338b3e537 
Full Text  http://radiology.rsna.org/content/249/2/445.full?sid=ed6f7b50-4693-4d96-8ad6-875338b3e537 
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Acquired Gastrointestinal Fistulas: Classification, Etiologies, and Imaging Evaluation Radiology July 2002 224:1 9-23; Published online May 30, 2002, doi:10.1148/radiol.2241011185 
Abstract http://radiology.rsna.org/content/224/1/9.abstract?sid=ed6f7b50-4693-4d96-8ad6-875338b3e537 
Full Text http://radiology.rsna.org/content/224/1/9.full?sid=ed6f7b50-4693-4d96-8ad6-875338b3e537 
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US case of the day. Gallstone ileus. Radiographics March 1995 15:2 493-495

Gastrointestinal manifestations of cystic fibrosis: radiologic-pathologic correlation. Radiographics July 1996 16:4 871-893

Gallbladder Stones: Imaging and Intervention Radiographics May 2000 20:3 751-766

From the RSNA Refresher Courses: Imaging Evaluation for Acute Pain in the Right Upper Quadrant Radiographics July 2004 24:4 1117-1135; doi:10.1148/rg.244035149

Bouveret Syndrome Radiographics July 2004 24:4 1171-1175; doi:10.1148/rg.244035222

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