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					                                   ANSWER TO WHAT’S YOUR DIAGNOSIS

                                                DIAGNOSIS: GALLSTONE ILEUS

Radiological findings                                               mon site of impaction is the terminal ileum (60%) followed
The plain radiograph (Figure 1) demonstrates dilated small          by jejunum and stomach.1,2
bowel loops and air in biliary tree while the small bowel                The clinical presentation of gallstone ileus is rarely spe-
series (Figure 2) shows contrast in a fistulous tract arising       cific and more than 30% of patients have no history of biliary
from the lateral wall of the second part of the duodenum and        symptoms. A history of endoscopic retrograde cholangiopan-
communicating with the gall bladder fossa. CT scan of the           creatography (ERCP) with or without sphincterotomy may
abdomen (Figure 3 a & b ) demonstrated pneumobilia, par-            be present in patients with known CBD stones (as in our
tial small bowel obstruction and a rim-like calcific density in     case). Early complications of ERCP are well recognized, but
the distal jejunum representing ectopic gallstone. A possible       there is little in the literature concerning complications de-
diagnosis of gallstone ileus was made. The classical radiologi-     veloping later. Gallstone ileus following ERCP has been pre-
cal triad involved in this condition is “Rigler’s triad” (partial   viously reported but in previous reports ileus always occurred
or complete intestinal obstruction, air in the biliary tree and     within a period less than 2 months after ERCP.3,4 This case
ectopic gallstone ).                                                illustrates a delayed complication as it occurred about seven
                                                                    months following ERCP for removal of CBD stones.
Discussion                                                               A plain abdominal radiograph may be helpful if it reveals
Gallstone ileus is a well recognized but rare complication          features of intestinal obstruction, an opacified density in
of cholelithiasis, resulting in 1% to 2% of all small bowel         the intestinal lumen or air in the biliary tree (pneumobi-
obstructions in patients over 70 years of age. The male to          lia). Pneumobilia is present in only one third of cases as the
female ratio is 1: 5 to 1:10. The impacted stone originates         cystic duct or CBD may be occluded by an inflammatory
from the gall bladder almost always entering the gastrointes-       process within the gallbladder.1,5,6 The air in the gallbladder
tinal tract through a biliary-enteric fistula and rarely through    is also not always identified on plain abdominal radiographs.
a cholecystoduodenal fistula. The stone passes spontaneously        Recognition of a gallstone in the intestinal lumen depends
without symptoms in 80% to 90% of cases. The most com-              upon the amount of calcium in the stone. Our case showed

 Figure 1. Plain abdominal radiograph.                                Figure 2. Small bowel series.

401                                                                       Ann Saudi Med 24(5) September-October 2004
                                                                     GALLSTONE ILEUS

no identifiable opaque density on the abdominal radiograph.
It showed only a partial small intestinal obstruction and air                                A
in the biliary tree.
     Ultrasound may provide the definite diagnosis and
obviate the need for further tests. Pneumobilia is noted as
increased echogenecity within the biliary tree and/or gall-
bladder. At times, it is possible to trace the dilated loops of
the small intestine to the obstructing calculus. However, the
gallstone may lie much deeper in the abdomen and may not
be identified on ultrasound due to overlying bowel gasses.6
     CT, on the other hand, is reported to be more sensitive
than plain abdominal radiographs and ultrasound in detecting
the three components of the Rigler’s triad. It can demonstrate
the cholecystoduodenal fistula and the size and number of
intraluminal gallstones even when they are not heavily calci-
fied.1,6,7 (Our patient demonstrated all the features of gallstone                           B
ileus.) If a contrast study of the upper GI tract is performed, it
may demonstrate a well-contained localized collection of con-
trast into the gallbladder lateral to the second portion of the
duodenum or opacification of the fistula (as in our case).
     The operative approach to gallstone ileus is enterotomy,
extraction of impacted stones and a careful search of the small
bowel for more stones and a biliary enteric fistula.3,8 Our pa-
tient had exploratory laparotomy, and a 2-cm size stone was
removed from the distal jejunum. A rudimentary gallbladder
with lots of adhesion forming a fistula with the duodenum was
left intact allowing the fistula to leak as a neutral cholecysto-                     Figure 3. (A) CT scan at the level of upper abdomen. (B) CT scan
duodenostomy.                                                                         at the level of mid abdomen.

1. Oikarinen H, Paivansalo M, Tikkakoski T, et al.       retrograde cholangiopancreatographies. J R Coll Surg     obstruction. AJR. 1997;168:1171-1180.
Radiological findings in biliary fistula and gallstone   Edinb. 1997;42:423-424.                                  6. Swift SE, Spencer JA. Gallstone ileus: CT findings. Clin
ileus. Acta Radiologica. 1996;37:917-922.                4. Gandhi A, Maxwell AJ, Wells S, Hobbis JH. Gallstone   Radiol. 1998;53:451-454.
2. Reisner RM, Cohen JR. Gallstone ileus: A review of    ileus following endoscopic sphincetrotomy. Br J Hosp     7. Balthazar EJ, Schechter LS. Air in gallbladder: A fre-
1001 cases. Am Surg. 1994;60:441-446.                    Med. 1995;54:229-230.                                    quent finding in gallstone ileus. AJR. 1978;131:219-222.
3. William IM, Hughes ODM, Hicks E, and Lewis            5. Maglinte DDT, Balthazar EJ, Kelvin FM, Megibow AJ.    8. Calvein PA, Richon J, Burgan S, Rohner A. Gallstone
MH. Gallstone ileus following multiple endoscopic        The role of radiology in the diagnosis of small bowel    ileus. Br J Surg. 1990;77:73-74.

Ann Saudi Med 24(5) September-October 2004                                                                                                 402