Gallstone Ileus: A Rare Case of Intestinal Obstruction

Gallstone ileus is a rare mechanical bowel obstruction caused by the impaction of a gallstone in the GI tract, most frequently in the terminal ileum and the ileocecal valve, secondary to a cholecystoenteric fistula. It predominantly affects elderly women with multiple comorbidities, which, together with non-specific and intermittent symptoms, delay the diagnosis. Imaging studies play a crucial role in diagnosis. Despite that, gallstone ileus continues to be associated with relatively high rates of morbidity and mortality. The optimal management of acute gallstone ileus remains controversial. The selection of a surgical procedure is primarily influenced by the clinical condition. Currently, enterolithotomy remains the most common and safest surgical method, with spontaneous closure of the fistulous tract. One-stage procedure is time-consuming, technically demanding, and is independently associated with a higher prevalence of mortality. Delayed cholecystectomy should be reserved for patients with persistent symptoms. This report describes the case of an 84-year-old man, partially dependent, who presented to the emergency department with a four-day history of fecaloid vomiting, food intolerance, and epigastric pain. The prompt evaluation and the high index of suspicion allowed for the guidance of imaging examination, correct diagnosis, and the surveillance and optimization in an intensive care unit. Despite the conservative therapy chosen, the patient has an unfavorable progression, indicating mechanical intestinal occlusion due to biliary ileus with possible ischemic involvement. A longitudinal enterolithotomy was performed. During hospitalization, the patient was subjected to an upper GI endoscopy with electrohydraulic lithotripsy that allowed the fragmentation of the stone. The patient progressed favorably, without any new episodes of biliary colic or intestinal obstruction within six months postoperatively. This case represents the importance of opting for less invasive approaches in frail patients with good long-term results.