Abstract
Gallstone ileus is a dramatic complication of gallstone disease, uncommon but not exceptional in a busy emergency department. It represents a cause of mechanical intestinal obstruction, which predominantly occurs in elderly and frail patients; this contributes to the high morbidity and mortality rates associated with this condition. The modern radiologist is frequently asked to determine the cause of bowel obstruction and should be aware of the most pictorial features of this unusual disease. Broadly speaking, abdominal radiography and ultrasonography alone are limited in detecting the cause of bowel obstruction, but the sensitivity for the preoperative diagnosis of gallstone ileus may be improved by combining the findings obtained by both techniques. Computed tomography is the modality of choice for the diagnosis of this disease: it may accurately describe the number, size, and location of migrated gallstones and the exact site of bowel obstruction, providing a detailed preoperative planning. Magnetic resonance imaging may be used in selected cases for an exquisite anatomic definition of the fistulous communication.
Highlights
Described in 1654 by Erasmus Bartholin, Danish physician and mathematician, gallstone ileus (GI) is an infrequent but dramatic complication of cholelithiasis; it constitutes an uncommon cause of mechanical bowel obstruction, but not exceptional in a busy emergency department
Seldom associated with GI (0–13.4%) choledochoduodenal fistulas represent another possible route for gallstones to access the enteric lumen. is type of biliary-enteric fistula (BEF) is most commonly due to the dorsal erosion of a duodenal ulcer. e incidence of choledochoduodenal fistulas ranges from 4% up to 61% as reported by Petrowsky and Clavien in their 2006 systematic review [7]
Magnetic resonance cholangiopancreatography (MRCP) together with computed tomography (CT) may play a potential role in the management of chronic stones inside the gallbladder, helping in estimating the tendency to fistulation towards the bowel [25]: gallstone size greater than 2 cm, loss or blurring of the fat plane between the gallbladder and duodenum, patients over 70 years old, and previous common bile duct endoscopic basket lithotomy have been identified as possible risk factors for bilioenteric fistula forming
Summary
GI represents a cause of mechanical intestinal obstruction resulting from gallstone migration and subsequent impaction into the bowel lumen It is unusual among the causes of mechanical bowel obstruction accounting for 0.4–5% of cases [1], with a constant incidence of 30–35 cases out of 1,000,000 admissions over a 45-year period [2] and a mortality and morbidity rate of around 7–30% due to delayed diagnosis or misdiagnosis [3]. Spontaneous closure of the fistulous tract is observed in more than 50% of cases; recurrence has been reported in 2–5% of patients, due to a remaining gallstone entering a persistent fistula, or unseen further stones left in the bowel lumen during previous surgery [1]. We provide a comprehensive description of imaging findings in gallstone ileus, detailing possible pitfalls and pathognomonic relevance of the most pictorial features
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