Stones passing through the papilla rarely have the diameter required for small intestine obstruction, even though sporadic cases have been reported.28 Gallstones may get impacted at any level of the gut, but the lower half of ileum is the site of predilection, followed by jejunum, sometimes even the duo­ denum or pylorus, and in contrast only rarely the colon or rectum proximal to the anal sphincter. At the impaction site spasm and edema are induced, decubital necrosis is a risk, followed by perforation. Character and course of ileus are determined chiefly by the level of obstruction. Clinical pattern Clinically gallstone ileus resembles other obstructions by colicky pains and vomiting, the passage of stools and wind is impeded and abdominal distension is present. This, however, may sometimes be hard to diagnose because the stone becomes arrested at a high level, and such a type of ileus does not produce ab­ dominal distension. The main reason why gallstone ileus is hard to recognize is due to the fact that it needs not be immediately permanent or complete. The stone in the course of its intestinal passage may get arrested transiently, before becoming permanently impacted. Ileus due to stone is thus less characteristic, its course is fluctuating and diagnosis delayed. Even nowadays patients are usually submitted to surgery after an average of 2-3 days, but even after 10-14 days after the stone's passage through the fistula, and occasionally even several weeks elapse. The general condition of these cases is usually poor, not only on account of the primary biliary disease, but also due to the advanced age of the victim and the protracted course of the obstruc­ tion. As a rule, biliary symptoms exacerbate before the stone penetrates into the gut, to subside afterwards; intestinal colic appears, sometimes hemorrhage, and later variously pronounced signs of intestinal obstruction and migratory pains according to the site of arrest or impaction of the stone. If wedged in the duodenal bulbus, or pylorus, the typical pattern of pyloro-duodenal stenosis is produced. If arrested in the duodeno-jejunal flexure or the upper jejunal loops, a high ileus is induced with gastrectasia and lacking any pronounced distension of intestinal loops. The lower in the small intestine impaction takes place, the more striking the signs of obstruction, distension of loops and succussion splash. In such cases the stone might be palpable on occasion per rectum or through a thin abdominal wall, more often, however, patients are so obese that even intestinal distension is hard to recognise. Plain films nearly always demonstrate fluid levels as proof of obstruction. Two signs should always be looked for which might point to the lithiatic cause of the obstruction. The first is the presence of gas in the biliary tract, having penetrated via the fistula. The second - stone in the gut, which however, is opaque in only about one-third of cases, or may be shown up by administration of 453 a little barium. Fig. 198a. Obstruction by gallstone is one of the most serious com­ plications of internal biliary fistula. It occurs approximately after every tenth,but also every fourth fistula (Portes, Niederle). Only in about half the cases is a correct preoperative diagnosis made (Kazda). Haffner believes that preoperative dia­ gnosis is possible in as much as 85% of cases. Any obscure case of ileus in an elderly female with a biliary past history should arouse suspicion if preceded by an exacerbation of biliary symptoms, and with plain films showing not only fluid levels in the small intestine, but frequently also gas in the biliary tract. The course of the ileus may vary to such a degree that a variety of types is distinguished (Postiglione and Cremaschi): Hyperacute type with hemorrhages or diarrhoea, acute type with rapid emergence of ileus, subacute type of Leriche, common and "typical", and chronic type, or the Karensky syndrome with long intervals between obstructive episodes; this is also called pseudocarcinomatous type. The last, - recurrent type is rare, with recurring obstruction due to the passage of stones. Treatment Therapy is exclusively surgical. Only sporadically could an impacted stone work itself loose spontaneously, traverse Bauhin's valve and pass through the colon without trouble. The general condition of aged patients is as a rule poor. Rehydration with physiological saline and 5% glucose is required, and losses of other electrolytes must be replaced according to the iontogram: this applies in particular to potassium loss, which occurs with late diagnosis and delayed surgery. Apart from potassium depletion reduction of proteins is also present. Blood transfusion is sometimes required before surgery is undertaken. Continuous aspiration of gastric and intestinal contents by nasogastric tube is essential. Broad spectrum antibiotics supplemented by vitamins B, C and K are also administered if biliary origin of the ileus is suspected. Operation is performed speedily on the same day that diagnosis is established. As the abdomen is entered the stone is usually identified easily on the borderline between distended and collapsed loops. A soft clamp is applied to the collapsed gut and it is necessary to find out whether the stone is firmly impacted. If it can be moved easily it is shifted proximally into a dilated but less damaged part of the gut. In no instance must the stone be forcibly expressed or attempts made to crush it. The overlying intestinal wall is usually thinned and internal decubitus may cause it to tear. The afferent dilated gut is evacuated by aspiration, and lavage and instillation of physiological saline solution with neomycin follows. The emptied loop is then gripped in a soft clamp at some distance proximal to the obstruction. The stone is removed by longitudinal enterotomy of sufficient length to make its cautiou& 454 removal without damage to the intestinal wall an easy matter. Fig. 249. The gut is carefully cleansed and sutured in two layers by atraumatic sutures. The intestinal clamps are now released and the remaining gut explored for any other stones and to identify any major damage caused by the deseending stone at sites of stoppage. The lower clamp is only released after the entire oral gut has been evacuated as much as possible, in order to avoid a sudden influx of toxic contents into the distal Fig. 249: Enterolithotomyafter evacuation of bowel by puncture aspiration. healthy loops. Resection of a gangrenous portion of the gut, or one of doubtful viability is required only exceptionally. The abdomen is closed without drainage, the nasogastric suction is left in position and parenteral nutrition and adjustment of homeostasis continued. According to the grade of intestinal damage oral feeding is resumed. As far as the biliary fistula is concerned: the biliary tract and fistula are not simultaneously operated on, or even explored in detail.ll, 22 Access from a lower laparotomy is usually difficult and the condition of patients far from good. The fistula closes spontaneously in most cases, and not infrequently this also terminates previous lithiatic symptoms. A decision whether supplementary surgery for cholelithiasis and fistula is still required is not made until later, after the patient has recovered, has been under continual observation, and investigated after an 455 interval of weeks, or even months. Such a procedure reduces immediate surgical mortality and has no adverse effect on the patient's prospects. Only about one-quarter of the series of our 31 patients who survived their operation for ileus were submitted to a second stage either for fistula or for lithiasis; in only one of these did gallstone ileus recur. In contrast, biliary symptoms were eliminated in 74%, according to follow-up for a minimum period of 5 years. On the basis of this experience reoperation after recovery from ileus is advised as a rule only for fistula which remains patent or where biliary symptomatology persists and the finding of residual stones and gallbladder or tract lesions requires intervention (cf. p. 373). Obstruction of colon by stone Impaction of gallstone in the colon is rare. Surgical procedure is similar to the principles applying to small bowel obstruction. Exceptionally a stone might become lodged in the anal canal proximal to the sphincter, as was the case in one of the author's patients. This stone was removed under an anesthetic following stretching of the sphincter. The stone penetrates into the colon usually via gallbladder fistula, which prob­ ably makes subsequent operation necessary more often than is the case with a cholecystoduodenal fistula. Pyloroduodenal obstruction by stone Should the gallstone become wedged in the immediate vicinity of the pyloric or bulboduodenal biliary fistula, not only the clinical pattern will differ, but also a somewhat modified surgical procedure is required.31• 40 Operation is embarked on following preparation as for pylorostenosis. Mter the situation has been elucidated by exploration, the stone is removed in the first place by duodenotomy or pylorotomy, or may be "milked" into the stomach and removed from an intact region by gastrotomy. The biliary tract and fistula are always explored concurrently by palpation and probing, but rarely by radiological methods, and dealt with according to the situation (p.374). Sometimes gallbladder and fistula are removed, sometimes left, while bile drainage into the gut must always be guaranteed as well as adequate stomach evacuation. In most cases an exclusion resection of the stomach is performed. Neither in these cases of pyloroduodenal obstruction, as in genuine biliary ileus, should we feel compelled to undertake immediate exacting biliary tract surgery. Thus we avoid the high surgical risk in exhausted patients, who sometimes may remain symptom-free permanently, even though a fistula with a small empty gallbladder has been left in situ. 456 Prognosis of surgery for gallstone ileas Mortality from biliary ileus used to be forbidding, but is declining gradually.