Editing Gallstone disease (section)

== '''Gallstone ileus''' ==

* Secondary to bilioenteric fistula - most frequently GB to duodenum or small bowel. Cholecystocolic fistulae are rare.
** Differentiate from Bouveret syndrome, in which the stone erodes into stomach and impacts at pylorus
* Impaction usually occurs in TI or ICV, and in most cases requires a stone >2.5cm
* Although it only causes 3% of SBO, more common in elderly females with virgin abdomen
* Clinical presentation
** Typical SBO
** Can see the 'tumbling stone' phenomenon, where pain changes location in the days leading up to presentation
* Radiographic
** Rigler's triad
*** SBO
*** Pneumobilia
*** Aberrant stone in GIT
** Need CT to clinch diagnosis, and see other stones within GIT
* Management
** Operation required - laparotomy - can't evaluate bowel properly with laparoscopy
*** Manually palpate for stones
*** Enterotomy 5-30cm proximal to stone location in antimesenteric bowel (healthier bowel) and squish stone out. Close enterotomy transversely.
*** Whether to fix the fistula is controversial.
**** Only 10% or so will have recurrent symptoms, and only 10% of these will need an operation, so total risk of needing another operation is about 1%
**** Single-stage cholecystectomy and closure of cholecystoenteric fistula has morbidity up to 60%, compared with 25% for just enterolithotomy
**** Probably overall it's best to leave the biliary system alone at initial operation.
**** Consider single-stage procedure in patients with favourable anatomy and physiology
** Delayed operation to fix fistula is unwarranted in asymptomatic patients