Clinical Radiology (1998) 53, 4 5 1 - 4 5 4

Gallstone Ileus: CT Findings

S. E. SWIFT and J. A. SPENCER
Department of Clinical Radiology, St James's University Hospital, Leeds, UK

We describe the CT findings of four consecutive cases of surgically proven gallstone ileus
and discuss the pathophysiology of gallstone liens and the impact of CT on diagnosis of the
condition. Swift, S.E. & Spencer, J.A. (1998). Clinical Radiology 53, 451-454. Gallstone Ileus:
CT Findings

Accepted for Publication 17 November 1997

Gallstone ileus is an uncommon but well recognized cause PATIENTS AND METHODS
of intestinal obstruction. In the elderly it has been said to
account for up to 25% of all causes of small bowel The study population comprised four patients, three
obstruction, and in this group of patients, who often have female and one male, aged 79 to 84 years, presenting with
concomitant systemic disease, gallstone ileus is a cause of small bowel obstruction. All had plain abdominal radio-
significant morbidity and mortality [1,2]. Presenting graphs on admission. CT was performed within 2 to 11 days
symptoms may be non-specific and Rigler's classic triad of admission. The patients were examined with either a
of small bowel obstruction, pneumobilia and an ectopic Somaton Plus S or a Somaton AR.T (Siemens, Erlangen,
gallstone [3] is infrequently present on the initial abdominal Germany). Oral contrast medium was not administered.
radiograph. Following 100ml of Omnipaque 300 1V (Nycomed, Bir-
Computed tomography (CT) is increasingly used to mingham, UK) given as a bolus injection, dynamic
investigate the acute abdomen, including cases of small sequence contiguous 10-mm slices were obtained from the
bowel obstruction [4,5]. In the elderly, whose presenting domes of the diaphragm to the symphysis pubis.
signs and symptoms are vague, CT is often performed to All cases had surgical proof of diagnosis. The pre-
look for underlying pathology, such as malignancy or intra- operative diagnosis made with abdominal radiography and
abominal sepsis. Previous case reports suggest that with CT were compared with the findings at surgery and these
gallstone ileus, CT can demonstrate key factors including examinations were further analysed retrospectively in the
the cholecystoduodenal fistula and the intraluminal gall- light of the surgical diagnosis.
stone in the small bowel even when this is not heavily
calcified [6-9]. We describe the CT findings in four cases of
surgically proven gallstone ileus to emphasize the utility of RESULTS
CT in the diagnosis of this relatively common cause of small
bowel obstruction in the elderly. The features of abdominal radiography and computed

Table 1 - Prospective radiological findings in four patients with gallstone ileus

Case

1 2 3 4

Abdominal radiograph
Pneumobilia + - - -
Small b o w e l obstruction + + + +
Ectopic gallstone + - - -
Gas in gallbladder fossa - - +* -
CT
Pneumobilia + - + -
Gallbladder fossa G a s - f l u i d level Gas Gas Gallstones
Small b o w e l obstruction + + + +
Transition point + + + +
Ectopic gallstone (density) + (calcified) + (cholesterol) + (intermediate) + t (mixed)
Free fluid + - + +
C h o l e c y s t o d u o d e n a l fistula + + + -
Thickened d u o d e n u m + + + -

* A n a b n o r m a l right u p p e r q u a d r a n t gas s h a d o w in case 3 was c o m m e n t e d u p o n but its significance not recognized.

t A n intraluminal m a s s in case 4 w a s considered to be a small b o w e l t u m o u r on the basis o f the C T examination.

C o r r e s p o n d e n c e to: D r J.A. Spencer, D e p a r t m e n t o f Clinical Radiology,

St J a m e s ' s University Hospital, Beckett Street, Leeds L S 9 7TF, UK.

9 1998 The Royal College of Radiologists.

452
tomography are summarized in Table 1 and illustrated in
Figs 1-4.
On the basis of the admission abdominal radiograph, the
diagnosis of gallstone ileus was suggested in only case 1.
Classic pneumobilia, i.e. gas within the bile ducts, was
detected by abdominal radiography in this case, who also
had a well documented history of gallstone disease. The
diagnosis of gallstone ileus was made pre-operatively with
CT in three of four cases. The key findings of abnormal gas
in the gallbladder fossa, cholecystoduodenal fistula and
abnormal duodenum were detected prospectively by CT in
these cases. These findings were subtle in the other case and
the prospective CT diagnosis was of small bowel obstruc-
tion due to an intraluminal tumour with incidental note of
gallstones within the gall bladder. The CT features of the
intraluminal gallstones were extremely variable, ranging
from classical calcification through to soft tissue density
(a)
(c)
Fig. 1 - (a-d) CT features of small bowel obstruction due to impacted intraluminal gallstones showing varied attenuation within distended small bowel. Note
the transition point (long arrow) immediately beyond the gallstone (short arrow) and the collapsed distal small bowel (curved arrow).
CLINICAL RADIOLOGY
mimicking a primary intraluminal tumour (Fig. 1). The
largest gallstone retrieved at surgery measured 4.5 cm. In
terms of the CT diagnosis of small bowel obstruction, for
each of our four cases the presence of small bowel dilata-
tion, the luminal transition point and distal collapsed small
bowel were clearly seen.
One patient died in the postoperative period of sepsis, and
the interval between admission and CT was 11 days in this
case.
DISCUSSION
The plain abdominal radiograph remains the mainstay in
radiological assessment of patients with clinically suspected
small bowel obstruction. CT is being increasingly used for
the investigation of small bowel obstruction [4,5]. In further
(b)
(d)
9 1998 The Royal College of Radiologists, Clinical Radiology, 53, 451-454.
 GALLSTONEmEUS
investigation of the condition, CT and small bowel enema
have complementary rather than competitive roles [10].
When abdominal radiography demonstrates characteristic
features of small bowel obstruction, CT has a role in
excluding complications such as strangulation when a trial
of non-surgical management is planned. When the abdom-
inal radiograph is not diagnostic of small bowel obstruction,
CT is preferred for acute presentations and small bowel
enema for sub-acute and intermittent symptoms [10]. The
results of CT affect patient management by influencing
decisions regarding surgical or conservative treatment,
reducing delay in accurate diagnosis and by recognition of
serious complications with attendant reduction in morbidity
and mortality [4,5,10].
(a)
(b)
Fig. 2 - CT features present in the gallbladder fossa and CT features of the
cholecystoduodenal fistula. (a) Gas-fluid level in the gallbladder, chole-
cystoduodenal fistula (arrow) and thickened duodenal wall. (b) Gas within
the gallbladder and free within the gallbladder fossa (arrow).
9 1998 The Royal College of Radiologists, Clinical Radiology, 53, 451-454.
453
Whilst detection of underlying malignancy or sepsis and
signs of strangulation or ischaemia are prime considerations
in performing CT for small bowel obstruction evaluation,
recognition of other causes of complicated small bowel
obstruction such as gallstone ileus is vital in the elderly
given its high mortality [1,2]. Symptoms and signs of
gallstone ileus are typically vague as the gallstone causes
only partial obstruction as it passes through the gastro-
intestinal tract. It finally becomes completely impacted as
the calibre of the small bowel decreases (e.g. towards the
terminal ileum) and as the stone gradually enlarges due to
sedimentation of intestinal contents [11]. Rarely the stone
may lodge in the duodenal bulb (Bouveret's syndrome)
[12].
(a)
(b)
Fig. 3 - CT features of associated pathophysiological changes in the fight
upper quadrant. (a) Pneumobilia, free perihepatic fluid and pleural fluid.
(b) Inflammatory change within the fat and free fluid.
454 CLINICAL RADIOLOGY

streaky change in the right upper quadrant intraperitoneal

fat, should raise the index of suspicion for gallstone ileus in
elderly patients with small bowel obstruction of unknown
cause.
In summary, early use of CT allows an accurate diagnosis
of gallstone ileus and is an important adjunct to clinical
examination and plain abdominal radiography in the assess-
ment of the elderly population with small bowel obstruction.

Acknowledgements. We would like to thank Ms Jane Howard and Dr

Tony Blakeborough for their help with preparation of the manuscript and
the Department of Medical Illustration for preparation of the figures.

REFERENCES
Fig. 4 - Abdominal radiograph showing a cholecystoduodenal fistula
(arrow) and small bowel obstruction (case 3).
On the plain abdominal radiograph in gallstone ileus
pneumobilia is not always present as occlusion of the
cystic duct or common bile duct often results from the
inflammatory process within the gallbladder [13]. Only one-
third of cases show classic pneumobilia. The appearance on
plain abdominal radiography of gas within the gallbladder
fossa is not always recognized [14] and this contributes to
the delay in diagnosis. This pitfall was clearly demonstrated
in our series where abnormal right upper quadrant gas
shadows were only correctly interpreted as gas within the
gallbladder fossa and duodenal bulb retrospectively after the
CT diagnosis had been made. In all our cases CT clearly
demonstrated the gallbladder fossa abnormalities (Fig. 2). It
should be noted that evidence of gallbladder fossa gas can
be very subtle and its detection aided by viewing the region
on wide CT window settings. The same technique may help
identify the fistulous tract, whose presence in two of our
examples was indicated only by a small pocket of gas
between the thickened duodenum and gallbladder fossa.
Even with CT, classic (ductal) pneuomobilia was only
demonstrated in two patients emphasizing the importance
of recognizing the gallbladder fossa abnormality. The pre-
sence of non-specific markers of an upper abdominal
inflammatory process, namely free perihepatic fluid and
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9 1998 The Royal College of Radiologists, ClinicalRadiology, 53, 451-454.