Description
Gallstone ileus is obstruction of the bowel due to impaction of one of more gallstones. To achieve this, stones usually have to be at least 2.5 cm in diameter.
A fistula develops between a gangrenous gallbladder and the duodenum or other parts of the gastrointestinal tract, allowing passage of the stone. Occasionally the stone may enter the intestine through a fistulous communication between the bile duct and the gastrointestinal tract. Stones less than 2.5 cm in diameter may traverse the alimentary canal without causing obstruction. When the gallstone lodges in the duodenum and causes gastric outlet obstruction, it is called Bouveret's syndrome.
Epidemiology
It accounts for only about 1-4% of causes of intestinal obstruction, but up to 25% of cases of intestinal obstruction in those over the age of 65. It is more common in women than in men and the incidence reflects the prevalence of gallstones with age and sex. It is regarded as 'rare and controversial'.
The most common site of impaction of gallstones is in the distal ileum, followed by the jejunum and the stomach.
Presentation
The presentation is usually that of distal obstruction of the small bowel but the symptoms and signs of gallstone ileus can be vague. It is important to make the diagnosis, as there is a high mortality in the usual age group.

Symptoms
Abdominal pain is an early sign with vomiting developing later. It tends to become progressively more severe.
Abdominal pain is colicky in nature, with freedom from pain between spasms. It is periumbilical and is not clearly localised.
Abdominal distension develops.
Initially the patient may pass stools or flatus but not later.
Vomiting occurs some hours after the onset of pain and it may be faeculent.
Signs
Patients with gallstones are often, but not invariably, obese.
The patient tends to look unwell.
The abdomen may be bloated and small bowel peristalsis may be visible.
Some slight and nonspecific tenderness of the abdomen is common.
Auscultation will reveal rushes, gurgling and tinkling sounds at times of pain.
Features of dehydration will develop.
Differential diagnosis
This is between other causes of intestinal obstruction. This may include adhesions from previous surgery. Malignancy almost never occurs in the small intestine. Large bowel malignancy tends to present as chronic blood loss when proximal and obstruction when distal. This is because the contents of the bowel are liquid in the first part and become progressively more solid as they traverse the colon.
Investigations
Plain abdominal X-ray should show the typical features of small intestinal obstruction. It may be possible to see air in the biliary tract. It may be possible to see a radio-opaque gallstone.
Rigler's triad of small bowel obstruction, pneumobilia and ectopic gallstones may be occasionally detected by plain radiograph or ultrasound. Computed tomography (CT) scanning invariably demonstrates a fistulous communication, intraluminal gallstone in the small bowel, pneumobilia and any other co-existing pathology contributing to the impaction of the gallstone. The interpretation of subtle signs on CT scanning requires skill but can increase the accuracy of the diagnosis. From the practical perspective, plain abdominal films demonstrate small bowel obstruction, ultrasound shows biliary tract pathology and CT makes the final diagnosis. Helical CT can be especially useful.
Blood tests should include FBC, U&E and creatinine, and LFTs.
In an elderly person, routine CXR and ECG before anticipated surgery are wise.
In view of anticipated surgery, blood should be group and cross-matched.
Associated diseases
Patients with gallstone ileus are often old and frail. Cases of gallstone ileus have been reported in patients whose intestines are strictured due to tuberculosis or other disease.
Management
An intravenous infusion is required to correct dehydration and to reduce the risk of surgery.
A nasogastric tube will decompress the stomach and avoid further vomiting.
Removal of the obstruction at laparotomy should be accompanied by a careful search for other gallstones proximal to the obstruction. It is generally recommended that those with chronic gallstone problems should undergo a later cholecystectomy, but it can be performed concurrently. Some authors say that definitive treatment of biliary pathology at the initial operation is the management of choice. Others disagree as it is a longer operation in a high-risk group and so the risk of complications is increased. One retrospective study concluded that treatment should be individualised and that removal of the stone through the bowel (enterolithotomy) should only be accompanied by cholecystectomy if the patient has good cardiorespiratory reserve and with absolute indications for biliary surgery at the time of presentation (the one-stage procedure).
Some surgeons manage to use a laparoscopic technique.
Complications
Complications are common as this is major surgery, usually in a group who are old and frail.
Prognosis
Because the condition tends to affect the old and frail, there is a 20% mortality. There appears to be no real difference in terms of the operative procedure performed, eg simple enterolithotomy to fistula repair

MRS R____ K________ , a 55 year old female was transferred from a local nursing home
She was admitted in a local Nursing home with abdominal pain & vomiting. She was treated as a case of acidity. In spite of the treatment for a week, she did not improve.
When she came to me, her symptoms were suggestive of intestinal obstruction (blockage). A CT scan of abdomen was undertaken. CT scan revealed that she had intestinal obstruction due to a large 5 centimeter stone. This is called Gall stone ileus.
How did the stone land up in her intestine?
No it was not a swallowed stone. This stone had formed in her Gall Bladder over many years. Due to its weight & chronic inflammation, the stone gradually perforated into her small intestine (duodenum). Since the stone was very large it could not pass thro the small intestine and got stuck in the last part of small intestine. Patient was having pain & constantly vomiting due to this blockage.
The treatment was done using minimal access surgery instead of making a big cut on her abdomen – laparotomy. Using laparoscopy, the site of blockage was identified. A small incision was made on her abdomen. The stone was cut open from the intestine (enterolithotomy) and the intestine was placed back into the abdomen.
The blockage was cleared and the patient recovered smoothly and was discharged in few days

What is a thyroidectomy?
A thyroidectomy is surgery to remove all or part of the thyroid gland.The thyroid gland is a small gland in the lower front of your neck. It takes iodine from the food you eat to make hormones. The hormones control the process of turning the food you eat into energy.
When is it used?
You may need to have part or all of your thyroid gland removed if: You have a lump in your thyroid gland that could be cancer. If cancer is found, removal of the gland can keep the cancer from spreading.Your thyroid gland is overactive and making too much thyroid hormone (a problem called hyperthyroidism).Instead of this procedure, other treatments may include:If you have a lump, you may choose to have repeat exams over many months or years and then have surgery if the lump grows. If you have cancer in your thyroid gland, there is some risk that the cancer will spread to other parts of your body.If you have an overactive thyroid gland, medicine and radioactive iodine treatments can usually control the problem. You may need surgery if these treatments do not control your thyroid gland.You may choose not to have treatment. Ask Dr. B C Shah about your choices for treatment and the risks.
How do I prepare for this procedure?
Make plans for your care and recovery after you have the procedure. Find someone to give you a ride home after the procedure. Allow for time to rest and try to find other people to help with your day-to-day tasks while you recover.Follow your provider's instructions about not smoking before and after the procedure. Smokers may have more breathing problems during the procedure and heal more slowly. It is best to quit 6 to 8 weeks before surgery.Some medicines (like aspirin) may increase your risk of bleeding during or after the procedure. Ask Dr. B C Shah if you need to avoid taking any medicine or supplements before the procedure.You may or may not need to take your regular medicines the day of the procedure, depending on what they are and when you need to take them. Tell Dr. B C Shah about all medicines and supplements that you take.Your provider will tell you when to stop eating and drinking before the procedure. This helps to keep you from vomiting during the procedure. Follow any other instructions your healthcare provider gives you.Ask any questions you have before the procedure. You should understand what your healthcare provider is going to do.
What happens during the procedure?
This procedure will be done at the hospital.You will be given general anesthesia to keep you from feeling pain. General anesthesia relaxes your muscles and you will be asleep. Dr. B C Shah will make a cut in your neck just above the collarbone. He or she will then remove all or part of the gland. Lab tests will be done right away during the procedure to check for cancer. Based on the test results, the provider may end the operation or may remove another part or all of the thyroid gland. The cut in your neck will then be closed. Rarely, thyroid cancer spreads to lymph nodes. If this has happened, you will need further treatment.The procedure will take 1 to 3 hours.
What happens after the procedure?
You may be in the hospital for 1 or 2 days. If all or a large part of the thyroid gland was removed, you will need to take thyroid hormone medicine for the rest of your life. If you have cancer, you may need to take radioactive iodine medicine to destroy any remaining thyroid tissue and cancerous cells. Ask Dr. B C Shah:how long it will take to recoverwhat activities you should avoid and when you can return to your normal activitieshow to take care of yourself at home what symptoms or problems you should watch for and what to do if you have them. Make sure you know when you should come back for a checkup.
What are the risks of this procedure?
Dr. B C Shah will explain the procedure and any risks. Some possible risks include:Anesthesia has some risks. Discuss these risks with your healthcare provider.You may have infection or bleeding.The nerves that control your speech may be injured. Damage to the nerves could make your voice hoarse. The damage may be temporary or lifelong.The parathyroid glands may be injured when all of the thyroid gland is removed. The hormones made by the parathyroid glands control the amount of calcium and phosphorus in the blood. You need to have the right levels of calcium and phosphorus in your blood so your nerves and muscles work well. If the parathyroid glands cannot function after the operation, you may need to take calcium pills or hormones.If thyroid cancer is found, it can return to the neck or other parts of the body. Fortunately, removal of the thyroid gland usually keeps this from happening.There is risk with every treatment or procedure. Ask your healthcare provider how these risks apply to you. Be sure to discuss any other questions or concerns that you may have.