A 79-year-old female was admitted with a one-week history of watery diarrhea, diminished appetite and episodes of coffee ground emesis. Physical examination revealed abdominal distension, lower abdominal tenderness, hypoactive bowel sounds, and melanotic stool. Pertinent laboratory data indicated a slight leukocytosis with a left shift, slight anemia, mild uremia, and an electrolyte imbalance.
A 79-year-old female was admitted with a one-week history of
watery diarrhea, diminished appetite and episodes of coffee ground
emesis. Physical examination revealed abdominal distension, lower
abdominal tenderness, hypoactive bowel sounds, and melanotic stool.
Pertinent laboratory data indicated a slight leukocytosis with a
left shift, slight anemia, mild uremia, and an electrolyte
imbalance. A gastrointestinal series demonstrated a fistula between
the duodenum, a focal extra-enteric barium collection, and the
hepatic flexure. Also identified was a large intra-luminal defect
obstructing the proximal jejunum, gas and barium in the ascending
and transverse colon, and refluxed barium in a non-dilated distal
and mid small bowel (figures 1-3).
Atypical gallstone ileus with cholecystoduodenal and
Following treatment for dehydration and electrolyte imbalance,
an exploratory laparotomy was performed. An enterolithotomy removed
a 3 ¥ 3 ¥ 2 cm gallstone. Along with removal of a barely
recognizable gallbladder, the fistulas were taken down and closed.
An intraoperative cholangiogram did not reveal biliary calculi. The
patient tolerated the surgery well and was discharged after a
The key to this diagnosis is recognizing the extra-enteric
barium between the duodenum and hepatic flexure as a contracted
gallbladder whose Aschoff-Rokitansky sinuses and cystic duct are
barely identifiable. Obstruction of the duct prevents air or barium
from entering the biliary tree. The normal duodenal and colonic
mucosa indicated that a diseased gallbladder had fistulized into
the adjacent hollow viscera and passed a stone, which eventually
obstructed the jejunum. Gas and barium in the transverse colon
result from the fistulous short circuit. Opacification of normal
distal and mid small bowel is secondary to an incompetent
While unprovable, we postulate that the cholecystoduodenal
fistula appears narrow because it is contracted. We also believe
another stone could have passed via the cholecystocolic fistula and
reached the rectum unimpeded.
Gallstone erosion into the gastrointestinal tract occurs in 3 to
5% of patients with cholelithiasis.1,2,3,4 Gallstone ileus causes 1
to 3% of all mechanical obstructions.1-4 In patients over the age
of 60, the incidence rises between 15 and 24%.1 The vast majority
of cases are found in elderly, obese females.
Generally, the sequence of events is cystic duct obstruction,
cholecystitis, pericholecystitis, abscess formation, fistulization
to an adjacent hollow viscus, passage of the stone and, eventually,
bowel obstruction. The obstructing stone causes pain, nausea,
vomiting, and intestinal distension, necessitating surgery. If the
stone directly enters the colon, it may pass asymptomatically to
the rectum. In patients with coexistent diverticular disease,
benign or malignant stricture, it is very likely to obstruct.5 More
commonly, the stone erodes through the postbulbar duodenum. Lodged
at this site, it can cause a gastric outlet obstruction.
Classically, it will progress through the small bowel and, if
greater than 2.5 cm in diameter, obstruct at the ileocecal
Besides opacifying the fistula and demonstrating the cause and
location of the obstruction, the gastrointestinal series is useful
in excluding other etiologies. Ruling out granulomatous disease,
proximal colonic diverticulitis and primary neoplasms of the
transverse colon, duodenum and pancreas makes surgical planning
The surgical procedure must be tailored to the individual.1,2,9
Palpation of the entire bowel subsequent to enterotomy and removal
of the obstructing stone is necessary to exclude the presence of
other enteric stones. Decisions about fistula transection, bowel
wall repair, and cholecystectomy must follow. If the inflamed
tissues are too friable, the abdomen should be closed and the
patient treated medically. Occasionally, the fistulas close
While the absence of jaundice indicates a patent biliary
duodenal connection-with or without a normal sphincter of
Oddi-cholecystectomy, fistula closure, and bowel wall repair would
significantly reduce the possibility of cholangitis and gallbladder
carcinoma, which has been found to be more common in patients with
cholecystoenteric fistulas.5 At the time of immediate or subsequent
elective cholecystectomy, an intraoperative cholangiogram could
clarify coexistent choledocholithiasis. If necessary, biliary
calculi can be removed during elective endoscopic cholangiography
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fistula with recurrent gallstone ileus. Arch Surg 119:1201-1203,
2. Doromal NM, Estacio R, Sherman H: Cholecysto-duodeno-colic
fistula with gallstone ileus: Report of a case. Dis Colon Rectum
3. Hrick H, Vander Molen RL: Duodencolonic fistula with
gallstone ileus. Am J Gastroenterol 69:711-715, 1978.
4. Vas Gossum M, Fastrez R, Issa S, et al:
Cholecystoduodenocolic fistula and gallstone ileus. Acta
Gastroenterol Belg 49:624-627, 1986.
5. Balthazar EJ, Guskin S: Cholecystoenteric fistulas:
Significance and radiographic diagnosis. Am J Gastroenterol
6. Clavien PA, Richon J, Burgan S, Rohner, A: Gallstone ileus.
Br J Surg 77:737-742, 1990.
7. Milson JW, Mackeigan JM: Gallstone obstruction of the colon:
Report of two cases and review of management. Dis Colon Rectum
8. Balthazar EJ, Schechter LS: Gallstone ileus: The importance
of contrast examination in the roentgenographic diagnosis. Am J
Roentgenol Radium Ther Nucl Med 125:374-379, 1975.
9. Shocket E, Evans J, Jonas S: Cholecysto-
duodeno-colic fistula with gallstone ileus. Arch Surg
Prepared by Alan Wecksell, MD, Polly J. Mirsky, MD, and Angelo
MD, North Shore University Hospital, New York University School