Correspondence

Gallstone Ileus

N Engl J Med 1997; 336:879-880March 20, 1997

Article

To the Editor:

Gallstone ileus results in considerable morbidity and mortality. Ileus is due to obstruction of the bowel by a large biliary stone that wedges in the terminal ileum or any other intestinal location (e.g., the colon). Prior formation of a cholecystoenteric fistula is common and has usually resulted from gallstone perforation of the duodenum or the colon. The occurrence of subsequent pneumobilia provides a strong clue to the diagnosis of gallstone ileus, but it is not found in all patients. Nonetheless, barium examination should be avoided in cases of acute abdominal illness.

First, barium administration in a patient such as the one described in Images in Clinical Medicine (Sept. 26 issue)1 is inappropriate. The patient had prolonged complete ileus, since she had had two days without bowel movements or passage of gas. In such circumstances, barium administration may aggravate symptoms of ileus as a result of barium-induced impaction, particularly in a paralytic bowel or in the presence of a prestenotic colon segment.

Second, this approach should not be used if there is a possibility of impaired intestinal viability or gastrointestinal perforation, because extravasation of barium into the peritoneal cavity can precipitate a severe and potentially fatal inflammatory response.2

Finally, in a patient with a two-day history of complete ileus, treatment should not be delayed any further by time-consuming imaging studies. But, on the basis of the history, clinical findings, and sonograms and plain abdominal radiographs showing possible pneumobilia or an ectopic gallstone, the patient should undergo emergency surgery (open laparotomy or laparoscopy3) shortly after admission, regardless of whether a definitive diagnosis has been established preoperatively.

Andreas M. Kaiser, M.D.
University Hospital, CH-8091 Zurich, Switzerland

3 References

1. 1

   Molmenti EP. Gallstone ileus. N Engl J Med 1996;335:942-942
   Full Text | Web of Science | Medline

2. 2

   Yamamura M, Nishi M, Furubayashi H, Hioki K, Yamamoto M. Barium peritonitis: report of a case and review of the literature. Dis Colon Rectum 1985;28:347-352
   CrossRef | Web of Science | Medline

3. 3

   Montgomery A. Laparoscope-guided enterolithotomy for gallstone ileus. Surg Laparosc Endosc 1993;3:310-314
   Web of Science | Medline

Author/Editor Response

Dr. Molmenti replies:

To the Editor: Dr. Kaiser bases his arguments on an isolated case report1 of barium peritonitis after a double-contrast colonic enema treated with irrigation and urokinase solution. He fails to justify avoiding the performance of a diagnostic upper gastrointestinal study in our patient, who presented without peritoneal signs, pneumobilia, or a history of surgery. Furthermore, initial films on admission showed a small amount of air in the colon and mostly fluid in the small bowel.

A search of the literature reveals multiple references to the use of contrast studies (such as the one we used) in the diagnosis of gallstone ileus.2-4

Dr. Kaiser also suggests that in a patient such as ours emergency surgery would have been appropriate. As stated in a textbook of modern surgical practice,5 “a patient in whom fluid and electrolyte imbalance develops after several days of illness may profit from 18 to 24 hours of preoperative preparation.” Indeed, the chief threat to the life of a patient such as ours may lie in the performance of “emergency surgery” without further preoperative preparation rather than in an imaging study. Our patient underwent surgery 18 hours after admission.

Ernesto P. Molmenti, M.D.
University of Pittsburgh, Pittsburgh, PA 15213

5 References

1. 1

   Yamamura M, Nishi M, Furubayashi H, Hioki K, Yamamoto M. Barium peritonitis: report of a case and review of the literature. Dis Colon Rectum 1985;28:347-352
   CrossRef | Web of Science | Medline

2. 2

   Reisner RM, Cohen JR. Gallstone ileus: a review of 1001 reported cases. Am Surg 1994;60:441-446
   Web of Science | Medline

3. 3

   Morrissey KP, McSherry CK. In: Blumgart LH, ed. Surgery of the liver and alimentary tract. 2nd ed. New York: Churchill Livingstone, 1994.
   

4. 4

   Clavien PA, Richon J, Burgan S, Rohner A. Gallstone ileus. Br J Surg 1990;77:737-742
   CrossRef | Web of Science | Medline

5. 5

   Jones RS. Intestinal obstruction. In: Sabiston DC, ed. Textbook of surgery: the biological basis of modern surgical practice. 15th ed. Philadelphia: W.B. Saunders, 1997:919.