The roentgen diagnosis of gallstone ileus.

Abstract

There are many communications in the literature describing gallstone or biliary ileus. In the period 1941 to 1950 88 papers on this subject were published. The majority of these are isolated case reports and few deal solely with the. radiographic diagnosis. Two factors serve to re-alert roentgenologists to an understanding and diagnosis of gallstone ileus. One is the high mortality of the disease; the other is the number of reports of gallstone obstruction from the surgical point of view which fail to mention the roentgen findings. As recently as 1950 a report (1) of 7 cases in which gallstone ileus was found at operation stated that “the roentgenographic examination appears to be of little value.” None of these cases were diagnosed before surgery. Denneen and Broderick (2) reported 1 case in a series of 10 which was recognized preoperatively. The present paper is based upon 8 cases in which the diagnosis was made or suggested prior to surgery or death. Four of these will be reported in some detail. In the opinion of the author, in the great majority of patients with this disease a diagnosis can easily be made. Early diagnosis is essential, since there is a notoriously long delay between the onset of symptoms and operation. The advanced age of most of the patients and concurrent cardiovascular-renal disease are additional reasons for the 50 per cent mortality which is the mean for this condition. In 1941, Rigler and his associates (3) reported 14 cases of gallstone ileus and discussed the diagnostic signs. The tenth published case of recurrent gallstone ileus was contributed by Noskin and Tannenbaum (4) in 1952. Lomhoff and Dubowy (5) reported a case of gallstone ileus associated with diverticulitis of the colon. The discovery of an obstructing calculus in the sigmoid, with the sigmoidoscope, was described by d'Abreu (6). Mayo and Brown (7), in 1949, reported the surgical aspects of 18 cases. Five diagnoses3 of mechanical ileus caused by an impacted gallstone were made at the Evanston Hospital from 1940 through 1951; this number represented 2.5 per cent of the 229 mechanical bowel obstructions in patients over eighteen years of age seen during that interval. This figure is in close agreement with those of Frimann-Dahl (8), 2 per cent, and of Rigler et al., 0.4 to 5.0 per cent. Recently Nemir (9) reported 8 cases of gallstone ileus treated surgically, representing 1.4 per cent of 549 cases of mechanical intestinal obstructions of all kinds. Erosion through the wall of the gallbladder into the alimentary canal is the common path by which a biliary calculus may gain entrance to the gut. A fistula is necessarily formed, usually cholecystoduodenal or cholecystojejunal. Rigler reported a choledochoduodenal fistula derived from the passage of a stone through the wall of the distal common duct into the duodenum. Many authors doubt if gallstones ever reach the intestine via natural channels.