Gallstone ileus analysis of radiological findings in 27 patients

https://doi.org/10.1016/j.ejrad.2003.11.011Get rights and content

Abstract

Purpose: We retrospectively compared the clinical value of plain abdominal film, abdominal sonography and abdominal CT in diagnosing gallstone ileus in 27 patients. Material and methods: 27 patients (23 women and 4 men, age range 58–96 years; mean age 71.5 years) with surgically proven gallstone ileus were submitted to plain film, sonography and CT of the abdomen. Abdominal plain films were performed in 19 cases in upright position (postero-anterior projection), in eight cases in supine position. Abdominal US were performed with 3.5 and/or 7.5 MHz probes. CT was performed with a helical unit (slice thickness 4 mm, reconstruction interval 4 mm, pitch 1.5), after intravenous contrast agent (120 ml) infusion (3 ml/s, 55 s acquisition delay from bolus starting) and using a power injector. The following findings were searched on: pneumobilia, air in gallbladder, cholecysto-digestive fistula, extraluminal fluid, bowel loops dilatation, intestinal air–fluid levels, ectopic stones. Results: Plain abdominal films showed the following findings: air–fluid levels (77.78% of cases), bowel loops dilatation (88.89%), site of obstruction (44.4%), pneumobilia (37.04%), air in gallbladder (3.70%), ectopic stone (33.33%). Abdominal sonography demonstrated bowel loops dilatation (44.44%), extraluminal fluid (14.81%), ectopic stones (14.81%), gallbladder abnormalities, (37.04%), pneumobilia (55.56%). CT findings retrospectively observed were: bowel loops dilatation (92.59%), air–fluid levels (37.04%), bilio-digestive fistula (14.81%), pneumobilia (88.89%), ectopic stone (81.48%), extraluminal fluid (22.22%). The Rigler’s triad, that is pneumobilia, bowel mechanical obstruction and ectopic stone detection was observed 4 times with RX (14.81%), 3 times with US (11.11%) and 21 times with CT (77.78%). Conclusions: Air–fluid levels and bowel loop dilatation were the radiological findings more frequently observed in our series. Plain abdominal film allowed us mainly to identify signs of obstruction, US were more effective in disclosing biliary pathology, CT allowed us to correctly diagnose biliary ileus with much higher accuracy.

Introduction

Gallstone ileus is an infrequent cause of intestinal obstruction accounting in the literature for 1–3% of all mechanical intestinal obstruction. It is more frequently observed in elderly women with a female:male ratio of 6:1 and has a high mortality level if not diagnosed early [1], [2], [3], [4]. Symptoms are often insidious at onset, with alternate phases of improvement and relapse corresponding to the progression of the stone along the digestive tract [2], [5], [6]. Plain abdominal radiographs have for long been the fundamental tool to recognise the pathology, the main signs being those described by Rigler et al. [7] who identified the classical triad composed by pneumobilia, detection of the ectopic stone and mechanical ileus and by Balthazar and Schechter [8] who described the sign of air in gallbladder.

Ultrasound [9], [10], [11], [12], [13] and CT scan [14], [15], [16], [17], [18], [19], [20], [21] have been reported to be powerful tools in obtaining early and definitive pre-operative diagnosis.

The purpose of this study is to retrospectively evaluate the diagnostic value of RX, US and CT of the abdomen.

Section snippets

Materials and methods

Between April 1997 and October 2002 we observed 27 patients (4 men, 23 women; age range 58–96 years; mean age 71.5 years) with surgically proven gallstone ileus. We retrospectively analysed RX, US and CT examination performed before the intervention.

Abdominal RX was performed in upright position in 19 cases, on supine patients in eight cases.

Ultrasound examination was performed with a 3.5 MHz convex probe and with a 7.5 MHz linear probe.

Helical CT was performed with the following parameters: 4 mm

Results

RX demonstrated in 24 patients radiological signs of bowel obstruction (88.89%) with evidence of bowel loop distension; in 21 (77.78%) air–fluid levels were also observed; in 10 (37.04%) pneumobilia was described; successive re-evaluation of the plain film and of the scout view of the CT increased the number of observation to 15 (55.56%). In nine patients (33.33%) an ectopic stone was described at first radiological report (Fig. 1), stones were observed in nine cases more using the window

Discussion

In our series, biliary ileus accounted for 2.73% of all intestinal obstruction that required surgery. In 16 patients the stone was located in the ileum (59.26%) (Fig. 1, Fig. 3, Fig. 4), in seven in the jejuneum (25.93%) (Fig. 5); one of the latter patients had two stones in the jejuneum; one patient had a stone located in stomach [22], one in duodenum (Bouveret’s syndrome) [22], [23], [24], [25], [26], [27], [28], [29], [30] (Fig. 9), one in colon [31], [32]. Furthermore, we have observed in

References (43)

  • M. van Hillo et al.

    Gallstone obstruction of the intestine: an analysis of ten patients and a review of the literature

    Surgery

    (1987)
  • L.G. Rigler et al.

    Gallstone obstruction: pathogenesis and roentgen manifestations

    JAMA

    (1941)
  • E.J. Balthazar et al.

    Air in gallbladder: a frequent finding in gallstone ileus

    AJR Am. J. Roentgenol.

    (1978)
  • T. Ripollés et al.

    Gallstone ileus: increased diagnostic sensitivity by combining plain film and ultrasound

    Abdom. Imaging

    (2001)
  • V. Simonovsky

    Biliary ileus: preoperative diagnosis by US. A report of two cases

    Eur. Radiol.

    (1994)
  • W. Renner et al.

    Ultrasound demonstration of a non-calcified gallstone in the distal ileum causing small-bowel obstruction

    Radiology

    (1982)
  • A. Lasson et al.

    Ultrasonography in gallstone ileus: a diagnostic challenge

    Eur. J. Surg.

    (1995)
  • E. Delabrousse et al.

    Gallstone ileus: CT findings

    Eur. Radiol.

    (2000)
  • I. Loren et al.

    Gallstone ileus demonstrated by CT

    J. Comput. Assist. Tomogr.

    (1994)
  • K. Grumbach et al.

    Gallstone ileus diagnosed by computed tomography

    J. Comput. Assist. Tomogr.

    (1986)
  • G.L.S. Leen et al.

    CT diagnosis of gall stone ileus

    Acta Radiol.

    (1999)
  • Cited by (142)

    • Gallstone ileus associated with cholecystogastric fistula: Case report, diagnosis and surgical treatment

      2021, International Journal of Surgery Case Reports
      Citation Excerpt :

      On examination, 3 main findings are sought: aerobilia (due to the presence of air in the gastrointestinal tract through the fistula with the gallbladder), loop distension due to the obstruction, and the ectopic gallstone [13]. There are divergent values regarding the finding of all elements of Rigler's triad in patients, ranging from 11.11% to 77.78% [5,14]. Cholangioresonance can be useful to assess the fistula and biliary tract, however, due to the clinical status of the patient, this exam is not the most appropriate, even more than the fistula, even though it can be seen in other exams, it does not always follow the biliary ileus [15].

    • Managing Gallstone Disease in the Elderly

      2021, Clinics in Geriatric Medicine
    View all citing articles on Scopus
    View full text