Article Type : Case Report
Title : Laparoscopic Management of Gallstone Ileus: A Case Report of a Rare Cause of Intestinal Obstruction
Abstract : Gallstone ileus is a rare but important cause of mechanical intestinal obstruction, accounting for 1–4% of all cases and predominantly affecting elderly patients. It results from the passage of a large gallstone into the intestinal lumen through a cholecystoenteric fistula. Traditionally managed by open surgery, recent advances have enabled selected cases to be treated laparoscopically. We report a case of gallstone ileus in an elderly female who presented with acute intestinal obstruction and was successfully managed by laparoscopic enterolithotomy. The case highlights the role of minimally invasive surgery in reducing postoperative morbidity in high-risk patients.
Introduction : Gallstone ileus is a rare complication of longstanding cholelithiasis and occurs when a gallstone enters the gastrointestinal tract through a biliary-enteric fistula and becomes impacted, most commonly in the terminal ileum 1. It is associated with significant morbidity and mortality due to delayed diagnosis, advanced age of patients, and associated comorbidities 2. The classic radiological Rigler’s triad includes pneumobilia, intestinal obstruction, and ectopic gallstone 3. Open enterolithotomy has traditionally been the standard surgical treatment; however, with advances in minimally invasive techniques, laparoscopic management is increasingly being reported with favorable outcomes4. We present a recent case of gallstone ileus managed successfully by laparoscopic enterolithotomy.
Case Presentation : A 68-year-old female with a known history of gallstone disease presented to the emergency department with complaints of colicky abdominal pain, vomiting, abdominal distension, and absolute constipation for three days. She had a history of recurrent dyspepsia and episodic right upper quadrant pain for the past five years. She was hypertensive and diabetic on irregular treatment.
On physical examination, the patient was dehydrated with tachycardia. The abdomen was distended with diffuse tenderness and hyperactive bowel sounds. No palpable mass was detected. Laboratory investigations revealed leukocytosis with mild electrolyte imbalance. Liver function tests were within normal limits.
Plain abdominal radiograph showed multiple air–fluid levels suggestive of small bowel obstruction. Contrast-enhanced CT scan of the abdomen revealed pneumobilia, dilated small bowel loops, and an ectopic gallstone measuring 3 cm impacted in the distal ileum, confirming the diagnosis of gallstone ileus.
After adequate resuscitation, the patient was taken up for emergency laparoscopic surgery. Diagnostic laparoscopy revealed a distended small bowel with a gallstone impacted approximately 40 cm proximal to the ileocecal junction. A small longitudinal enterotomy was made, the stone was extracted, and the enterotomy was closed intracorporeally. The cholecystoenteric fistula was not addressed in the same sitting. The operative time was 95 minutes with minimal blood loss.
The postoperative period was uneventful. The patient resumed oral intake on postoperative day 3 and was discharged on day 6. At three-month follow-up, the patient remained asymptomatic.
Discussion : Gallstone ileus is a rare surgical emergency seen predominantly in elderly women with longstanding gallstone disease. It results from pressure necrosis of the gallbladder wall leading to the formation of a cholecystoenteric fistula, most commonly cholecystoduodenal. The ileum is the most frequent site of gallstone impaction due to its narrow lumen and less active peristalsis5-8.
Clinical diagnosis is often delayed because the symptoms are nonspecific and intermittent. CT scan is considered the gold standard for diagnosis, with high sensitivity in demonstrating Rigler’s triad and the exact location of obstruction9.
The optimal surgical management remains controversial. Options include10:
Enterolithotomy alone
One-stage procedure (enterolithotomy + cholecystectomy + fistula repair)
Two-stage procedure
Enterolithotomy alone is currently preferred in elderly and high-risk patients due to shorter operative duration and lower morbidity. Laparoscopic enterolithotomy, although technically demanding, has shown promising results with reduced postoperative pain, shorter hospital stay, and faster recovery.
Recent literature supports the use of laparoscopy in hemodynamically stable patients, provided adequate surgical expertise is available. In our case, minimally invasive surgery was chosen due to the patient’s comorbid conditions, resulting in an excellent outcome.
Gallstone ileus is an uncommon but serious cause of small bowel obstruction in elderly patients. High clinical suspicion and early CT imaging are essential for prompt diagnosis. Laparoscopic enterolithotomy is a safe and effective treatment option in carefully selected patients and offers the advantages of minimal invasiveness, reduced postoperative complications, and faster recovery. With increasing surgical expertise, minimally invasive management is likely to become the preferred approach in the future.
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