The incidence of gallstone ileus (GSI) is increasing. Current treatment options include enterolithotomy with or without cholecystectomy and repair of the biliodigestive fistula. Although most surgeons defer the management of the biliodigestive fistula to avoid the associated morbidity and mortality, this can lead to increased rate of recurrence of GSI by the remaining gallstones. More than 130 cases of recurrent GSI were reported in published works, and the incidence of recurrent GSI is reported to be between 5% and 20%. Some cases of second recurrent attacks have also been reported. Most cases were reported in elderly women with faceted stones during the first 2 months from the first episode of GSI. This article reviews the current treatment options for more than 4,300 reported cases of GSI. A treatment algorithm is recommended based on the severity of the inflammation around the gallbladder, including cholecystolithotomy as a third treatment approach that aims to reduce the risk of recurrent GSI.

We report a case of cholelithiasis followed by gallstone ileus, documented with serial computed tomography (CT) scans, that responded to conservative therapy. An 80-year-old woman was admitted because of abdominal pain and vomiting. Six months previously, she had presented with abdominal pain and nausea of sudden onset. A CT scan showed thickening of the gallbladder wall and a gallbladder stone. She refused cholecystectomy, and the abdominal pain gradually improved in response to conservative treatment. On admission, plain abdominal radiographs showed obstruction of the proximal small bowel. A CT scan revealed disappearance of the gallbladder stone, fluid-filled bowel loops, and the presence in the small bowel of an impacted stone (major axis, 45 mm; minor axis, 23 mm). We diagnosed gallstone ileus. Because the gallstone was not large, we inserted a stomach tube and administered conservative treatment. One day after admission, CT showed that the impacted stone had migrated to the transverse colon. Four days after admission the impacted stone was not seen on plain abdominal radiography. Five days after admission, follow-up CT revealed pneumobilia but no impacted stone. Because the symptoms had improved the patient resumed oral intake of liquids The patient was discharged 14 days after admission and is doing well.

To help the surgeon in decision making when treating a patient with recurrent gallstone ileus (RGSI).

A systematic review related to RGSI was performed using the databases CINAHL, EMBASE, MEDLINE via PubMed from May 1912 to April 2015. All languages were included and the grey literature was also searched. The abstracts were explored for relevance to the topic and full texts obtained as appropriate. A manual search was carried out by scrutinising the reference lists of all the full text articles and further articles were identified and obtained. Total of 903 articles were identified, 656 were excluded after abstract review, 247 full text articles were reviewed and 91 articles selected for final analysis. There were 113 cases of RGSI.

There were 113 cases of RGSI reported in 91 articles. The majority of the recurrences, 62.6%, occurred within 6 wk of the index event. The male to female ratio was 1:7. The mean age was 69.6 years (SD 11.2) with a range of 38-95 years. The small bowel was the commonest site of impaction (92.2%). Treatment data was available for 104 patients. The two main operations performed were: (1) Enterolithotomy without repair of biliary fistula in 70.1% of all patients with a procedural mortality rate of 16.4% (12/73) and (2) a single stage surgery approach involving enterolithotomy with cholecystectomy and repair of the biliary enteric fistula in 16.3% with a procedural mortality of 11.7% (2/17). A subset analysis over last 25 years showed mortality from eneterolithotomy was 4.8% while single stage mortality was 22.2%. Enterolithotomy alone was the commonest operation performed for RGSI with four patients (5.4%) having a further recurrence of gallstone ileus.

Enterolithotomy alone or followed by a delayed two-stage treatment approach is the preferred choice offering low mortality and reduced risk of recurrence.

A 73-year-old man with gallstone disease was admitted with right upper quadrant abdominal pain. He was treated for cholecystitis with intravenous antibiotics. Two days later, he reported of new onset left iliac fossa pain, with tenderness and guarding. An abdominal X-ray demonstrated small bowel obstruction, a CT scan demonstrated an impacted gallstone within the proximal ileum. He was treated for a gallstone ileum and underwent an uncomplicated laparotomy, small bowel enterotomy and removal of a faceted gallstone. Three months later, the patient re-presented with generalised abdominal pain, guarding and rebound tenderness. Small bowel obstruction was again demonstrated with an impacted gallstone within the distal ileum seen on CT scan. A second laparotomy revealed two further faceted gallstones, which were removed through an enterotomy. The densely adherent gallbladder to the duodenum precluded a surgical repair of the cholecystoduodenal fistula. He made an uneventful recovery and was subsequently discharged home.

Gallstone ileus is a mechanical bowel obstruction caused by a biliary calculus originating from a bilioenteric fistula. Because of the limited number of reported cases, the optimal surgical method of treatment has been the subject of ongoing debate.

A retrospective review of the Nationwide Inpatient Sample from 2004 to 2009 was performed for gallstone ileus cases treated surgically by enterotomy with stone extraction alone (ES), enterotomy and cholecystectomy with fistula closure (EF), bowel resection alone (BR), and bowel resection with fistula closure (BF). Patient demographics, hospital factors, comorbidities, and postoperative outcomes were reported. Multivariate analysis was performed comparing mortality, morbidity, length of stay, and total cost for the different procedure types.

Of the estimated 3,452,536 cases of mechanical bowel obstruction from 2004 to 2009, 3268 (0.095%) were due to gallstone ileus-an incidence lower than previously reported. The majority of patients were elderly women (>70%). ES was the most commonly performed procedure (62% of patients) followed by EF (19% of cases). In 19%, a bowel resection was required. The most common complication was acute renal failure (30.44% of cases). In-hospital mortality was 6.67%. On multivariate analysis, EF and BR were independently associated with higher mortality than ES [(odds ratio [OR] = 2.86; confidence interval [CI]: 1.16-7.07) and (OR = 2.96; CI: 1.26-6.96) respectively]. BR was also associated with a higher complication rate, OR = 1.98 (CI: 1.13-3.46).

Gallstone ileus is a rare surgical disease affecting mainly the elderly female population. Mortality rates appear to be lower than previously reported in the literature. Enterotomy with stone extraction alone appears to be associated with better outcomes than more invasive techniques.

Gallstone ileus is an uncommon type of mechanical intestinal obstruction caused by an intraluminal gallstone, and preoperative diagnosis is difficult in the Emergency department. This study is a retrospective analysis of the clinical presentation of 5 patients with gallstone ileus treated between 2000-2010. Clinical features, diagnostic testing, and surgical treatment were analyzed. Five patients were included: 2 cases showed bowel obstruction; 2 patients presented a recurrent gallstone ileus with prior surgical intervention; and one patient presented acute peritonitis due to perforation of an ileal diverticula. In all cases CT confirmed the preoperative diagnosis. In our experience, gallstone ileus may present with clinical features other than intestinal obstruction. In suspicious cases CT may be useful to decrease diagnostic delay, which is associated with more complications.

Mirizzi syndrome and cholecystoenteric fistula with or without gallstone ileus are late complications of gallstone disease. We previously suggested that the natural history of Mirizzi syndrome may not end with just a cholecystobiliary fistula and that the continuous inflammation in the triangle of Calot area may result in a complex fistula involving the biliary tract and the adjacent viscera. The purpose of this study was to establish the relationship of Mirizzi syndrome with cholecystoenteric fistulas.

We retrospectively reviewed the records of all patients older than aged 18 years submitted to emergency or elective cholecystectomy from 1995 to 2006. Of 5,673 cholecystectomies performed during that period, we found 327 (5.7%) patients with Mirizzi syndrome and 105 (1.8%) patients with cholecystoenteric fistula. Ninety-four (89.5%) patients with cholecystoenteric fistula also had an associated Mirizzi syndrome.

Cholecystoenteric fistula was associated with Mirizzi syndrome (p < 0.0001), increased age was associated with Mirizzi syndrome and cholecystoenteric fistula (p < 0.0001), and female gender was associated with Mirizzi syndrome (p < 0.0001).

When during surgery for gallstone disease a cholecystoenteric fistula is encountered, the possibility of an associated Mirizzi syndrome must be considered. The findings of this study confirm the association of Mirizzi syndrome with cholecystoenteric fistula.

Gallstone ileus is a rare disease and accounts for about 1-3% of mechanic ileus of the small bowel, but for 25% of all small bowel obstructions in patients older than 65 years. Concomitant cardiorespiratory diseases or diabetes are frequent in older patients and responsible for the high mortality rate. The aim of the present study was to evaluate and discuss different surgical approaches and to analyze the clinical outcome.

Four patients with a mean age of 72 years were treated for gallstone ileus at our hospital in the last 10 years. Patients history, operative strategy and their outcome is elucidated and a review of the recent literature is given.

In all patients the operative strategy was a one-stage procedure including enterolithotomy, cholecystectomy and closure of the fistula. The 30-day mortality rate was 25%.

One-stage procedure prevents from cholangitis, cholecystitis and recurrent ileus caused by further gallstones but bears the risk of enteric or biliary leakage after fistula closure. It should therefore be reserved for patients presenting in good general condition with a low degree of cholecystitis.

Gallstone is a common disease with a 10% prevalence in the United States and Western Europe. However, it is only symptomatic in 20-30% of patients, with biliary pain "colic" being the most common symptom. Complications of asymptomatic gallstone disease are generally rare, with an incidence of <1 %/yr. The most common complications of gallstone disease are acute cholecystitis, acute pancreatitis, ascending cholangitis, and gangrenous gallbladder. Less frequent complications include Mirizzi syndrome, cholecystocholedochal fistula, and gallstone ileus. Mirizzi syndrome and cholecystocholedochal fistula are two manifestations of the same process that starts with impaction of a gallstone in the gallbladder neck that results in obstruction of the bile duct, causing jaundice. The gallstone may erode into the bile duct, causing cholecystocholedochal fistula. Gallstone ileus refers to small bowel obstruction resulting from the impaction of one or more gallstones after they have migrated through a cholecystoenteric fistula. An accurate diagnosis is essential to the management and prevention of further complications. A variety of imaging and endoscopic modalities are used to make the diagnosis once the condition is suspected clinically. Treatment should be tailored to each individual patient. Management choices include ERCP, lithotripsy (endoscopic or extracorporeal), and surgery. Prognosis is frequently related to early recognition, management of any comorbid conditions, and careful selection of treatment modalities.

Gallstone ileus is a surgical emergency that occurs almost exclusively in the elderly. It is of increasing significance with current demographic changes. Clinical records and diagnostic imaging of 15 consecutive patients treated for gallstone ileus at one hospital over a 6-year period were reviewed. The median patient age was 80 years. Six plain-film diagnoses were made correctly. Contrast studies provided a diagnosis of intestinal obstruction in four patients. Abdominal X-ray findings were assessed incorrectly in two patients, with one false-positive and one false-negative result. The median preoperative hospital stay was 2 days. Three patients had Bouveret's syndrome, two of whom required a gastrostomy and enterolithotomy, and one of whom required a gastroenterostomy. The remaining 12 patients underwent enterolithotomies. Only one patient underwent a cholecystectomy. There was one postoperative death. No patient had biliary symptoms on follow-up. Gallstone ileus is a difficult clinical and radiologic diagnosis. Enterolithotomy alone is adequate treatment in the elderly, and subsequent cholecystectomy is not mandatory.

We report our experience with laparoscopic surgical treatment of gallstone ileus, along with cholecystectomy and repair of a cholecystoduodenal fistula. The technique and advantages are discussed. To our knowledge, this is the first such case done laparoscopically to be reported in the world literature.

Thirty-seven patients (33 women and four men, median age 78 years) were operated on for gallstone ileus over a 12-year period with a median follow-up of 6.2 years. Twenty-three patients (62 per cent) had serious concomitant diseases. Plain abdominal radiographs performed at admission were diagnostic in only 17 patients (46 per cent) and other procedures such as ultrasonography, gastrointestinal contrast studies and computed tomographic scan were required in ten patients (27 per cent). The diagnosis was made before operation in 27 patients (73 per cent) but in only 17 (46 per cent) at admission. Obstructing stones were located in the terminal ileum in 27 patients (73 per cent), in the proximal ileum or jejunum in five (14 per cent), in the duodenum in two (5 per cent), and in the colon in three (8 per cent). In six instances (16 per cent), more than one stone was involved. Cholecystduodenal fistula was the most frequent fistula type (n = 25, 68 per cent), followed by cholecystcolonic (n = 2, 5 per cent) and cholecystduodenocolonic (n = 2, 5 per cent) types. The site of the fistula was not established in the other eight instances. A one-stage procedure consisting of the removal of the impacted stone, fistula repair and cholecystectomy was performed in eight patients, two of whom died. A second group of six patients underwent a two-stage procedure consisting of enterolithotomy followed by elective biliary surgery, with no mortality. Removal of impacted stones was the only surgical treatment in the remaining 23 patients, with five deaths. Operative mortality and morbidity rates associated with the initial procedure did not differ significantly among the three therapeutic groups, which were comparable in terms of patient age, associated concomitant diseases and APACHE II score. However, later biliary complications were prominent in patients treated only by enterolithotomy. These results support the view that a one-stage procedure is, when feasible, a valid option and may be the procedure of choice. When local or surgical conditions argue against a one-stage procedure, biliary surgery at a second stage should be considered, if residual stones are present. In poor risk patients, non-operative methods should be considered.

A patient with gastric outlet syndrome (Bouveret's syndrome) caused by a large gallstone impacted in the duodenal bulb was successfully treated by extracorporeal shock-wave lithotripsy. Thus, open abdominal surgery could be avoided. For disintegration of the stone, three consecutive lithotripsy procedures were necessary. Thereafter, stone fragments could be extracted endoscopically. Extracorporeal shock-wave lithotripsy could become a non-surgical alternative in patients with obstruction of the duodenum caused by a gallstone.

The clinical data of 35 patients with gallstone ileus treated between 1970 and 1984 at the Department of Surgery of the University Hospital of Freiburg were retrospectively analysed with respect to duration of symptoms prior to surgery, preoperative diagnostic, operative procedure and outcome. No reliable test could be found that will lead the clinician to the correct diagnosis in most cases. The classical sign of gallstone ileus--small bowel obstruction combined with pneumobilia in the plain abdominal X-ray--was apparent only in 20%. So, a high index of suspicion, especially in old female patients with small bowel obstruction and prompt surgical intervention will decrease mortality. Enterotomy with removal of the stone without simultaneous cholecystectomy can be recommended as a safe procedure even in very old patients.

A 61 year old man presented with peritonitis which at laparotomy was found to be due to an enterolith perforation of a blind end of a previous side-to-side ileal anastomosis.