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Rolling in the Deep: Imaging Findings and Diagnostic Pearls in Gallstone Ileus

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Rolling in the Deep: Imaging Findings and Diagnostic Pearls in Gallstone Ileus Hindawi Surgery Research and Practice Volume 2020, Article ID 1421753, 10 pages https://doi.org/10.1155/2020/1421753 Review Article Rolling in the Deep: Imaging Findings and Diagnostic Pearls in Gallstone Ileus Carnevale Aldo,1 Motta Lorenzo ,2 Labaj Olgerta,1 Cossu Alberto,2 Uccelli Licia,3 and Giganti Melchiore2 1Department of Diagnostic and Interventional Radiology, University Radiology Unit, University Hospital of Ferrara, Ferrara, Italy 2Department of Morphology, Surgery and Experimental Medicine, Section of Radiology, University of Ferrara, Ferrara, Italy 3Department of Morphology, Surgery and Experimental Medicine, Section of Nuclear Medicine, University of Ferrara, Ferrara, Italy Correspondence should be addressed to Motta Lorenzo; [email protected] Received 28 October 2019; Accepted 8 April 2020; Published 24 April 2020 Academic Editor: Cato T. Laurencin Copyright © 2020 Carnevale Aldo et al. (is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 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. (e 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. 1. Introduction have been reported, offering new insights into this unusual entity. Firstly described in 1654 by Erasmus Bartholin, Danish GI represents a cause of mechanical intestinal ob- physician and mathematician, gallstone ileus (GI) is an struction resulting from gallstone migration and subsequent infrequent but dramatic complication of cholelithiasis; it impaction into the bowel lumen. It is unusual among the constitutes an uncommon cause of mechanical bowel ob- causes of mechanical bowel obstruction accounting for struction, but not exceptional in a busy emergency de- 0.4–5% of cases [1], with a constant incidence of 30–35 cases partment. Despite medical advances over the last 350 years, out of 1,000,000 admissions over a 45-year period [2] and a it still represents a diagnostic and therapeutic dilemma, with mortality and morbidity rate of around 7–30% due to a high mortality rate since it predominantly occurs in el- delayed diagnosis or misdiagnosis [3]. Indeed, this entity derly, debilitated, and multimorbid patients. It follows that a remains a significant diagnostic and treatment challenge. prompt diagnosis is mandatory to avoid complications and GI usually occurs in debilitated patients with multiple allow an accurate preoperative planning. In the last two comorbidities who had suffered from past episodes of cal- decades, some advances in the radiologic diagnosis of this culous cholecystitis; elderly women are more frequently condition by sonography, abdominal radiography, com- affected, with a female-to-male ratio of 6 :1 [4] up to 16 :1 [5] puted tomography, and sporadically magnetic resonance and an average age of 65−75 years. 2 Surgery Research and Practice (e most common underlying cause of GI is represented erodes the gallbladder into the duodenum, resulting in a by the presence of a biliary-enteric fistula (BEF). Chol- cholecystoduodenal fistula (60%) and consequent gastric ecystoduodenal fistulas are the most frequent due to the outlet obstruction, since the site of impaction occurs in the proximity of the gallbladder to the duodenum, seen in proximal duodenum or pylorus; less frequent locations are 32.5–96.5% of cases (Table 1); cholecystojejunal, chol- the gallbladder fossa and the stomach [1, 12]. ecystocolonic (5–25%), cholecystoduodenal-colonic (2.5%), Management of GI is controversial because of patient age and cholecystogastric fistulas [6] are as well described in the and multiple comorbidities. Whilst open surgery has been literature, but are rarer (Figure 1; Table 1). Although seldom the cornerstone of treatment, other approaches have been associated with GI (0–13.4%) choledochoduodenal fistulas more recently employed, including endoscopy, laparoscopic represent another possible route for gallstones to access the surgery, and lithotripsy [13], although too few cases have enteric lumen. (is type of BEF is most commonly due to the been reported to formulate a conclusion about their effec- dorsal erosion of a duodenal ulcer. (e incidence of chol- tiveness compared with standard methods. In selected cases, edochoduodenal fistulas ranges from 4% up to 61% as re- especially with elder and frail patients, endoscopy can be ported by Petrowsky and Clavien in their 2006 systematic considered as a first-line noninvasive approach. Suitability of review [7]. Less frequently, in patients who have previously the endoscopic retrieval of a dislodged gallstone primarily undergone ERCP and endoscopic Oddi’s sphincterotomy, a depends on its size and final site of impaction along the large gallstone may migrate into the common bile duct, enteric lumen. Endoscopically accessible large gallstones are subsequently accessing the duodenum through the dilated amenable to various options of fragmentation techniques, major papilla. including intra/extracorporeal lithotripsy, electrohydraulic GI onset is generally preceded by many episodes of silent lithotripsy, and mechanical lithotripsy. Furthermore, en- or symptomatic biliary disease: recurrent and chronic in- doscopic repair of BEF is now a well-established possibility. flammation of the gallbladder and surrounding tissues leads Among the surgical options, enterotomy with stone to adhesion formation, pressure necrosis, and wall erosion, extraction alone appears to be more suitable: it is less in- with subsequent cholecystoenteric fistulation and gallstone vasive, with a low rate of complications [11]. In addition, migration. spontaneous closure of the fistulous tract is observed in more (e gallstone must be greater than 2–2.5 cm to cause than 50% of cases; however, recurrence has been reported in bowel obstruction in the absence of a digestive pathology 2–5% of patients, due to a remaining gallstone entering a which can determine stenosis. Indeed, many smaller calculi persistent fistula, or unseen further stones left in the bowel may pass spontaneously through a normal gastrointestinal lumen during previous surgery [1]. Hence, alternative tract and may be excreted uneventfully in the stool [9]. (e treatment options include enterolithotomy, cholecystec- usual site of stone impaction is the distal ileum and the tomy, and fistula repair as a one-stage procedure, or ileocecal valve (60%) since their lumens are narrow, but the enterolithotomy with delayed cholecystectomy and fistula possible locations of the lodged gallstone are diverse: jeju- repair when the patient has recovered from the acute episode num (16%), stomach (14%), colon (4%), and duodenum [13]. (3.5%) [10]. While the gallstone causing obstruction is Here, we provide a comprehensive description of im- usually only one, it is important to be aware that additional aging findings in gallstone ileus, detailing possible pitfalls calculi may be present in the bowel proximal to the site of and pathognomonic relevance of the most pictorial features. occlusion, since they may represent the cause of GI recur- rence after treatment. Some authors advocated that a cy- 2. Conventional Abdominal Radiography lindrical or faceted morphology of the calculus may be predictive of recurring GI [9]: this relies on the assumption Plain abdominal radiography (XR) is routinely performed in that these shapes imply multiplicity of stones, which should emergency settings as a first-line imaging approach for alert the surgeon to the possibility of further stones in the investigating bowel obstruction; for decades, it had main- remaining bowel. tained the gold standard role in the diagnosis of GI. From a clinical point of view, a large part of the patients (e classic and pathognomonic imaging finding in GI will have a well-known history of prior acute cholecystitis or consists in the association of air in the biliary tree (pneu- biliary symptoms. Most of the BEF are clinically silent. GI mobilia), ectopic radio-opaque stone, and small bowel ob- takes an insidious course: the presentation is typically struction (SBO), named after the radiology pioneer Leo nonspecific, with usually intermittent obstructive symptoms Rigler as “Rigler’s triad.” Originally described for abdominal as the stone progresses aborally through the bowel, including XR, the modern radiologist is more likely to encounter its nausea, vomiting, vague abdominal pain, and distension CT counterpart [14] (Figure 2). However, this characteristic [11]. (is intermittent onset
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