1. The American Journal of Surgery 183 (2002) 56 –57
Clinical image
Gallstone ileus with cholecystoduodenal fistula
Junji Machi, M.D., Ph.D., Alvin Ikeda, M.D., John Yarofalir, M.D., Toshiro Yahara, M.D.,
Nobuyuki Miki, M.D.
University of Hawaii and Kuakini Medical Center, 405 N. Kuakini St., Suite 601, Honolulu, HI 96817, USA
Fig. 3.
Fig. 1.
Fig. 4.
Fig. 2.
within normal limits. A computed tomography with contrast
demonstrated ascites in the upper abdomen, air and contrast
An 88-year-old man came to the emergency room with a in the contracted gallbladder (arrow in Fig. 1), and a pos-
3-week duration of intermittent abdominal pain, followed sible laminated gallstone at the terminal ileum (arrow in
by nausea and vomiting for 3 days. He did not have any Fig. 2).
history of abdominal surgery or biliary diseases. He was Surgery is indicated for a patient with gallstone ileus to
afebrile and physical examination showed moderate abdom- remove a stone from the intestinal tract. Performance of
inal distension without tenderness. White blood cell count concomitant biliary procedures during the same operation is
was 10,900/mm3 with 45% bands. Liver function tests were determined mainly by the condition of a patient, but also by
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2. J. Machi et al. / The American Journal of Surgery 183 (2002) 56 –57 57
factors such as the extent of the inflammation around the with adhesion was noted at the hepatoduodenal ligament
biliary tract, the condition and location of biliary enteric fistula area. Intraoperative ultrasonography showed a contracted
(some fistulas close with fibrous remnant), and the presence or gallbladder containing small stones and air. Cholecystoduo-
absence of biliary obstruction due to bile duct stones. Intraop- denal fistula was identified and accurately localized by ul-
erative cholangiogram can provide valuable information but trasonography, which demonstrated the dynamic movement
may be difficult to perform because cannulation for contrast of fluid and air between the gallbladder and duodenum in
injection is not easy or possible. Intraoperative ultrasonogra- real-time (arrows in Fig. 4). The bile duct was normal in
phy is helpful in this setting, because the ultrasound scanning size (6 to 7 mm) without stones or pneumobilia on ultra-
can be performed without any tissue dissection. sound examination. Because the patient was in a stable
In this patient, laparotomy was performed with the use of condition, cholecystectomy was performed. The fistula was
intraoperative ultrasonography. Near the terminal ileum, detected and excised. The duodenal opening was closed by
there was a palpable stone, confirmed by intraoperative sutures with an omental patch. Although the patient had
ultrasonography (arrow in Fig. 3). The 3.5 ϫ 2 cm stone renal failure and respiratory failure, he recovered from these
was removed through ileotomy. A marked inflammation postoperative complications and was discharged.