Gall Stone Ileus and Recurrence: Management Dilemma for the Operating Surgeon

Gallstone ileus (GSI) is a rare complication of gallstone disease. It occurs as a result of the passage of a stone from the biliary tract into the gastrointestinal tract via an abnormal pathway (bilio-enteric fistula). Chronic inflammatory processes result in gall bladder adhering and subsequently eroding into the intestines, leading to a fistula. It is a surgical emergency seen in the elderly who often present as being unwell, with abdominal pain, distension, and vomiting. Imaging such as a CT scan is diagnostic in confirming small bowel obstruction. Management usually involves relief of obstruction by removing the impacted gallstone. Despite surgical intervention, a small proportion of patients develop recurrent symptoms or recurrent gallstone ileus, usually within a few weeks of initial presentation. The recurrence of symptoms during index admission is extremely rare and can be challenging to diagnose and manage. The morbidity and mortality remain high in elderly patients. We report an 89-year-old patient who presented with small bowel obstruction. The CT scan confirmed gallstone ileus as a result of a stone impacted in the mid-small bowel. The patient had a laparotomy with extraction of the stone. No migrating stones were felt proximally. Five days postoperatively, he developed recurrent gallstone ileus confirmed on a CT scan and had to undergo another surgery to relieve the obstruction. We aim to investigate various management strategies for recurrent gallstone ileus, ranging from the commonly practiced approach of simple stone extraction to more definitive surgical interventions, including fistula repair, which may provide a more comprehensive solution.