Single-stage laparoscopic treatment of a cholecystoduodenal fistula with perforated small bowel ileus and fibrinous purulent peritonitis. A single case study




cholecystolithiasis, cholecystoenteric fistula, gallstone ileus, small bowel perforation, Rigler’s triad


Gallstone ileus is a rare complication of recurrent cholecystitis and one of the rarest causes of mechanical bowel obstruction, with an increasing incidence in the elderly. We present a case of multiple small bowel perforations of the jejunum due to gallstone obstruction and the incidental finding of high‑grade appendiceal mucinous neoplasia of the appendix. To our knowledge, this is the first such case to be described and completely resolved by a laparoscopic approach.

An 83‑year‑old woman presented to our emergency department with severe vomiting, constipation, and deterioration of her general condition. A computed tomography scan revealed thickening of the gallbladder with a continuous aerobe to the duodenum, a mechanical obstruction of the small intestine at the transition to the ileum, and a thickened and calcified appendix. Due to a high suspicion of gallbladder perforation with the formation of a bilio‑duodenal fistula, the patient underwent an emergency exploratory laparoscopy, which revealed a small bowel perforation in three segments with marked local fibrinous, purulent, and stercoral peritonitis of the left hemiabdomen. The gallstone was retrieved through the perforated small bowel, and a partial small bowel resection and a cecal wedge resection were performed laparoscopically. Small bowel continuity was restored with an anisoperistaltic side‑to‑side jejuno‑jejunostomy. The patient was discharged on postoperative day eight.

Despite advances in imaging, gallstone ileus remains a diagnostic challenge. Because the disease occurs predominantly in elderly patients, gallstone ileus remains associated with high morbidity and mortality. It remains unclear from the literature whether the optimal surgical management of bilioenteric fistula is best resolved by a single‑stage or a two‑stage approach.



Alzerwi NAN, Idrees B, Alsareii S, Aldebasi Y, Alsultan A. The regularity of the site of impaction in recurrent gallstone ileus: a systematic review and meta-analysis of reported cases. Can J Gastroenterol Hepatol. 2021;2021:5539789.

Attenberger C, Guthoff I, Anthuber M, eds. Der Gallensteinileus als seltene Erstmanifestation des Gallensteinleidens. German Medical Science GMS Publishing House; 2009.

Ayantunde AA, Agrawal A. Gallstone ileus: diagnosis and management. World Journal of Surgery. 2007;31(6):1292-7.

Balthazar EJ, Schechter LS. Air in gallbladder: a frequent finding in gallstone ileus. American Journal of Roentgenology. 1978;131(2):219-22.

Bossart PA, Patterson AH, Zintel HA. Carcinoma of the gallbladder. The American Journal of Surgery. 1962;103(3):366-9.

Browning LE, Taylor JD, Clark SK, Karanjia ND. Jejunal perforation in gallstone ileus — a case series. Journal of Medical Case Reports. 2007;1(1).

Clavien P-A, Richon J, Burgan S, Rohner A. Gallstone ileus. British Journal of Surgery. 1990;77(7):737-42.

Cooperman AM, Dickson ER, ReMine WH. Changing concepts in the surgical treatment of gallstone ileus. Ann Surg. 1968;167(3):377-83.

Courvoisier LG. Casuistisch-statistische Beitrage zur Pathologic und Chirurgie der gallenwege; 1890.

Doogue MP, Choong CK, Frizelle FA. Recurrent gallstone ileus: Underestimated. ANZ Journal of Surgery. 1998;68(11):755-6.

Gonzalez-Urquijo M, Rodarte-Shade M, Lozano-Balderas G, Gil-Galindo G. Cholecystoenteric fistula with and without gallstone ileus: A case series. Hepatobiliary & Pancreatic Diseases International. 2020;19(1):36-40.

Gupta M, Goyal S, Singal R, Goyal R, Goyal S, Mittal A. Gallstone ileus and jejunal perforation along with gangrenous bowel in a young patient: A case report. North American Journal of Medical Sciences. 2010:442-3.

Halabi WJ, Kang CY, Ketana N, et al. Surgery for gallstone ileus: a Nationwide comparison of trends and outcomes. Ann Surg. 2014;259(2):329-35.

Huang S-F, Han Y-H, Chen J, Zhang J, Huang H. Surgical management of cholecystoenteric fistula in patients with and without gallstone ileus: an experience of 29 cases. Front Surg. 2022;9:950292.

Inukai K. Gallstone ileus: a review. BMJ Open Gastroenterology. 2019;6(1):e000344.

Kirkland KC. Gallstone intestinal obstruction. JAMA. 1961;176(6):494.

Lassandro F, Gagliardi N, Scuderi M, Pinto A, Gatta G, Mazzeo R. Gallstone ileus analysis of radiological findings in 27 patients. European Journal of Radiology. 2004;50(1):23-9.

Lassandro F, Romano S, Ragozzino A, et al. Role of helical CT in diagnosis of gallstone ileus and related conditions. American Journal of Roentgenology. 2005;185(5):1159-65.

Lee C-H, Yin W-Y, Chen J-H. Gallstone ileus with jejunum perforation managed with laparoscopic-assisted surgery: rare case report and minimal invasive management. Int Surg. 2015;100(5):878-81.

Liau S-S, Bamber A, MacFarlane M, Alberts J. A case of gallstone-induced small bowel necrosis masquerading as clinical appendicitis. Clin J Gastroenterol. 2009;2(3):238-41.

Limjoco UR. Gallstone jejunal perforation: surgical implications. Military Medicine. 1990;155(1):42-4.

Martin F. Intestinal obstruction due to gall-stones. Ann Surg. 1912;55(5):725-43.

Mir SA. Management and outcome of recurrent gallstone ileus: A systematic review. World Journal of Gastrointestinal Surgery. 2015;7(8):152.

Mukaramov AM, Mukaramov OM. Perforatsiia toshcheĭ kishki zhelchnym kamnem [Perforation of the jejunum by a gallstone]. Klin Khir (1962). 1990;(2):56-7. Russian. PMID: 2342283.

Nakao A, Okamoto Y, Sunami M, Fujita T, Tsuji T. The oldest patient with gallstone ileus: report of a case and review of 176 cases in Japan. The Kurume Medical Journal. 2008;55(1/2):29-33.

Nuño-Guzmán CM. Gallstone ileus: One-stage surgery in a patient with intermittent obstruction. World Journal of Gastrointestinal Surgery. 2010;2(5):172.

Räf L, Spangen L. Gallstone ileus. Acta Chir Scand. 1971;137(7):665-75. PMID: 5149154. .

Ravikumar R, Williams JG. The operative management of gallstone ileus. The Annals of The Royal College of Surgeons of England. 2010;92(4):279-81.

Reisner RM, Cohen JR. Gallstone ileus: a review of 1001 reported cases. Am Surg. 1994 Jun;60(6):441-6. PMID: 8198337..

Requena-López AA, Mata-Samperio BK, Solís-Almanza F, Casillas-Vargas R, Cuadra-Reyes LA. Comparación de técnicas quirúrgicas en el íleo biliar y sus resultados. Cir Cir. 2020;88(3):292-6.

Rigler LG, Borman CN, Noble JF. Gallstone obstruction. Pathogenesis and roentgen manifestations. Journal of the American Medical Association. 1941;117(21):1753.

Ripollés T, Miguel-Dasit A, Errando J, Morote V, Gómez-Abril SA, Richart J. Gallstone ileus: increased diagnostic sensitivity by combining plain film and ultrasound. Abdominal Imaging. 2001;26(4):401-5.

Shelton J, Samad MA, Juhng J, Terry SM. Unusual presentation of bouveret syndrome resulting in both gastric outlet obstruction and small bowel obstruction with perforation. Medicines (Basel). 2022;9(3).

Syme RG. Management of gallstone ileus. Can J Surg. 1989 Jan;32(1):61-4. PMID: 2642721.

Ueber Gallensteinileus. Dtsch med Wochenschr. 1902;28(10):168-70.

VanLandingham SB, Broders CW. Gallstone Ileus. Surgical Clinics of North America. 1982;62(2):241-7.

Wahshaw AL, Bartlett MK. Choice of operation for gallstone intestinal obstruction. Ann Surg. 1966;164(6):1051-5.

Wakefield EG, Vickers PM, Walters W. Cholecystoenteric fistulas. Surgery 1963;54:716.

Yu C-Y. Value of CT in the diagnosis and management of gallstone ileus. World Journal of Gastroenterology. 2005;11(14):2142.






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