Gallstone ileus with concomitant cholecystoduodenal and cholecystocolonic fistulae: surgical management with enterolithotomy, fenestrating partial cholecystectomy, and primary fistula repair – a case report

Abstract

Introduction and importance:

Gallstone ileus with concomitant cholecystoduodenal and cholecystocolonic fistulae is rare. This report describes the successful one-stage surgical management of a high-risk patient without preoperative computed tomography (CT) imaging.

Case presentation:

A 46-year-old morbidly obese woman (BMI >45 kg/m²) with atrial fibrillation presented with symptoms of bowel obstruction for more than 2 weeks. Despite complete mechanical small-bowel obstruction, she had no perforation or ischemia. The diagnosis was confirmed by plain radiographs and an oral contrast study; CT was deferred because of acute kidney injury.

Clinical discussion:

At laparotomy, a large obstructing gallstone was found in the distal ileum together with a second large stone in the gallbladder at the fistula site. A single-stage procedure (enterolithotomy, fenestrating partial cholecystectomy, and primary repair of both fistulae) was performed. The patient recovered well and was discharged on postoperative day 12.

Conclusion:

This case illustrates that definitive one-stage surgery can yield good short-term outcomes in carefully selected high-risk patients with dual fistulae and a residual stone when clinical and basic imaging findings are concordant, even without cross-sectional imaging.

Introduction

Gallstone ileus is a rare mechanical cause of small-bowel obstruction, accounting for 1–4% of all cases and up to 25% of non-strangulated small-bowel obstructions in patients over 70 years of age^[1^]. It occurs in 0.3–0.5% of patients with cholelithiasis and still carries a mortality rate of 12–27% despite modern surgical care^[2^]. The condition predominantly affects elderly females with a history of chronic cholecystitis^[2^]. Pathophysiologically, repeated episodes of cholecystitis lead to adhesion formation, pressure necrosis, and eventual biliary-enteric fistula, most commonly cholecystoduodenal (60–75% of cases)^[3^]. Cholecystocolonic fistulae are far less common, and the simultaneous presence of both cholecystoduodenal and cholecystocolonic fistulae remains rare, with only isolated case reports documented in the literature^[4,5^].

HIGHLIGHTS

• A rare presentation of gallstone ileus secondary to simultaneous cholecystoduodenal and cholecystocolonic fistulae in a morbidly obese patient.

• Successful one-stage surgery was performed without preoperative CT imaging because of acute kidney injury.

• A fenestrating partial cholecystectomy was used safely in a hostile gallbladder field, with primary repair of dual fistulae.

• Favorable short-term outcome was achieved despite a high-risk profile (BMI > 45 kg/m² and atrial fibrillation).

• This demonstrates that definitive management can be considered when a large residual gallstone poses an imminent risk of recurrent obstruction.

The classic Rigler triad is pathognomonic but present on plain radiography in fewer than 15% of cases; contrast-enhanced computed tomography (CT) remains the gold-standard diagnostic modality^[6^]. However, in patients with acute kidney injury (AKI) or in resource-limited settings, CT may be contraindicated or unavailable. Surgical management remains the cornerstone of treatment and includes enterolithotomy alone, a one-stage procedure, or a two-stage approach^[7^]. In difficult cases with a hostile gallbladder or multiple fistulae, fenestrating partial cholecystectomy (Strasberg technique) offers a safe option to minimize bile-duct injury^[8^].

We present a case of gallstone ileus secondary to concomitant cholecystoduodenal and cholecystocolonic fistulae in a relatively young (46-year-old) but physiologically high-risk patient with morbid obesity and atrial fibrillation. The patient was successfully managed with a one-stage operative approach without preoperative CT, a decision driven by the intraoperative finding of a second large gallstone at imminent risk of causing further obstruction. This report adds to the sparse literature on dual fistulae and demonstrates that definitive single-stage management can yield good short-term outcomes even in high-risk patients when patients are carefully selected.

This case report has been prepared in accordance with the SCARE 2025 checklist^[9^].

Case presentation

A 46-year-old woman with a background of hypertension, atrial fibrillation, previous cerebrovascular accident (7 years prior), and treated congestive cardiac failure (therapy discontinued in 2024) presented with symptoms of bowel obstruction for more than 2 weeks. She reported progressive intolerance to oral intake, bilious vomiting, and abdominal distension. Although she had complete mechanical small-bowel obstruction, she tolerated the condition remarkably well, without clinical or radiological signs of bowel perforation or ischemia and had intermittent bowel motions prior to admission. Her only prior surgery was an appendicectomy at age eight. She was markedly obese, with a BMI > 45 kg/m².

On examination, the abdomen was soft with epigastric fullness and localized tenderness but no peritonism. Digital rectal examination revealed an empty rectum. Vital signs showed tachycardia (112 bpm) with a blood pressure of 120/79 mmHg; she was afebrile. Nasogastric aspiration yielded bile-stained fluid. Laboratory investigations demonstrated AKI (creatinine 163 µmol/L, eGFR of 29 mL/min/1.73 m², urea 20.5 mmol/L), hyponatremia (129 mmol/L), and a cholestatic liver-function pattern.

Plain abdominal radiographs (erect and supine) demonstrated markedly distended small-bowel loops consistent with mechanical obstruction (Fig. 1). An oral contrast study confirmed the diagnosis of small-bowel obstruction (Fig. 2). Intravenous contrast-enhanced CT was contraindicated due to AKI. Non-contrast CT was considered but deferred: the clinical picture and basic imaging already confirmed mechanical obstruction; the patient had been resuscitated and was stable for laparotomy; and further delay for imaging was judged unnecessary in the local resource context.

Figure 1.

Plain abdominal radiographs. (A) Erect view showing multiple dilated small-bowel loops with air-fluid levels consistent with mechanical obstruction. (B) Supine view confirming centrally dilated loops; no free intraperitoneal air is visible.

Figure 2.

Oral contrast study. (A, B) Sequential images demonstrating hold-up of contrast within dilated small-bowel loops without passage into the colon, confirming complete mechanical obstruction.

Differential diagnosis

Common causes of mechanical small-bowel obstruction in a patient with a prior appendicectomy include adhesions, internal hernia, neoplasm, and intussusception. The prolonged history without peritonism, the radiographic pattern of distal small-bowel obstruction, and the absence of a palpable mass or external hernia made adhesive obstruction or gallstone ileus the leading possibilities. Intra-operative findings confirmed gallstone ileus secondary to dual biliary-enteric fistulae.

At midline laparotomy, a large obstructing calculus was identified in the distal ileum approximately 30 cm proximal to the ileocecal valve, with proximal dilatation and distal collapse. The gallbladder was chronically inflamed with dense adhesions and patent cholecystoduodenal and cholecystocolonic fistulae. A second, larger gallstone was noted within the gallbladder at the level of the fistulae, posing an imminent risk of further obstruction. The hepatocystic triangle was hostile.

A proximal longitudinal enterotomy was performed; the obstructing stone was evacuated, and the enterotomy was closed transversely. Fenestrating partial cholecystectomy (Strasberg technique) was carried out, leaving the posterior gallbladder wall on the liver bed; the cystic-duct orifice was identified and oversewn from within. Both duodenal and colonic defects were repaired primarily with interrupted two-layer 3-0 polydioxanone (PDS) sutures. The nasogastric tube was advanced beyond the duodenal repair and left on free drainage for 7 days. A subhepatic pencil drain was placed. The extracted gallstones are shown in Figure 3.

Figure 3.

Extracted gallstones: (A) Large obstructing ileal calculus. (B) Second large gallbladder stone recovered from the fistula site.

Postoperatively, the patient was managed in the intensive care unit for 1 day. Total parenteral nutrition (TPN) was commenced on day 2 and continued until day 7 to protect the duodenal repair. Clear oral fluids were introduced on day 5 and escalated as tolerated. The subhepatic pencil drain remained in situ for 10 days. She developed a minor superficial surgical-site infection that was managed with regular wound dressings. The patient was discharged on postoperative day 12 and was reviewed in the surgical outpatient department on day 21 with no complications.

Patient perspective

The patient expressed relief at the resolution of her prolonged obstructive symptoms and reported that she had returned to her usual daily activities by the time of the day-21 outpatient review.

Discussion

Gallstone ileus is an uncommon but clinically significant cause of mechanical small-bowel obstruction, typically affecting elderly patients with multiple comorbidities. The present case is notable for the simultaneous presence of cholecystoduodenal and cholecystocolonic fistulae – a combination reported in only a limited number of cases^[4,5^] – and for its occurrence in a relatively young but physiologically high-risk patient with morbid obesity (BMI >45 kg/m²) and atrial fibrillation.

The underlying pathogenesis involves recurrent inflammation leading to adhesion formation, pressure necrosis, and eventual biliary-enteric fistulation^[3^]. While cholecystoduodenal fistulae account for the majority of cases (60–75%), the coexistence of both fistulae reflects advanced, long-standing disease and carries the additional risk of colonic bacterial reflux and cholangitis.

Preoperative imaging in this case was limited to plain abdominal radiographs and an oral contrast study because of AKI. Although contrast-enhanced CT remains the diagnostic modality of choice, with a reported sensitivity of approximately 90–93%^[2^], timely diagnosis can be achieved in selected cases using basic imaging modalities when clinical findings are concordant. Non-contrast CT can demonstrate pneumobilia, an ectopic stone, and obstruction, but was not pursued once the decision for laparotomy had been reached.

The optimal surgical management of gallstone ileus remains controversial. Available strategies include enterolithotomy alone, a one-stage procedure, or a two-stage approach^[7,10,11^]. In a landmark review of 1001 cases, Reisner and Cohen reported lower immediate mortality with enterolithotomy alone (11.7%) compared with one-stage procedures (16.9%)^[1^]. More recent population-based data from the Nationwide Inpatient Sample by Halabi et al. demonstrated lower in-hospital mortality rates for enterolithotomy alone (approximately 5–8%) compared with one-stage procedures (approximately 10–17%), as well as reduced operative time and physiological stress^[7^]. Contemporary reviews and institutional series support an individualized approach, with enterolithotomy preferred in frail patients and one-stage surgery reserved for stable patients with residual stones or complex fistulae^[10–12^]. When one-stage biliary surgery is required in a hostile field, fenestrating rather than reconstituting subtotal cholecystectomy may reduce bile-duct injury, although bile leak is more common^[8,13^]. However, these findings are influenced by selection bias. Definitive surgery may reduce the risk of recurrent gallstone ileus and ongoing biliary pathology in appropriately selected patients^[7,11^]. A comparison of surgical strategies is summarised in Table 1.

Table 1.

Comparison of surgical strategies in gallstone ileus.

Parameter	Enterolithotomy alone	One-stage procedure	Relevance to current case
Operative complexity	Lower	Higher	–
Operative time	Shorter	Longer	–
Physiological stress	Reduced	Increased	–
In-hospital mortality	~5–12 %	~10–17 %	–
Recurrence of gallstone ileus	5–10 %	<1 %	Inadequate (second large stone present)
Persistent biliary symptoms	Possible	Rare	One-stage preferred
Need for second operation	Up to 10–20 %	Rare	–
Ideal patient profile	Elderly, frail, unstable	Stable, residual stones/fistulae	One-stage justified

In the present case, the intraoperative identification of a second large gallstone at the fistula site, together with the presence of dual fistulae, provided strong justification for definitive one-stage management. After fluid resuscitation and correction of electrolyte imbalance, the patient was stable enough to tolerate the additional operative time. The obstructing stone was located approximately 30 cm proximal to the ileocecal valve. Enterolithotomy was performed via a longitudinal enterotomy with transverse closure. A fenestrating subtotal cholecystectomy (Strasberg technique) was undertaken because of the hostile operative field^[8^], and both duodenal and colonic defects were repaired primarily using two-layer 3-0 PDS sutures.

Fenestrating partial cholecystectomy leaves the posterior wall in situ and avoids dissection within an inflamed hepatocystic triangle. Compared with the reconstituting subtype, it carries a higher risk of postoperative bile leak but eliminates a gallbladder remnant that could harbor recurrent stones^[8^]. Primary repair of both enteric defects was feasible because the surrounding tissues were healthy.

Postoperative management was tailored to protect the duodenal repair. This included prolonged nasogastric decompression for 7 days, early TPN and gradual reintroduction of oral intake from day 5 – standard precautions after complex duodenal repair in the setting of recent obstruction, mural edema and a high BMI.

Delayed intervention in gallstone ileus risks progression to bowel ischemia, perforation, and sepsis. The presence of a large residual stone and dual fistulae further increased this risk and supported definitive surgery once the anatomy had been defined.

This case highlights that dual biliary-enteric fistulae should be anticipated in advanced gallstone disease. It further demonstrates that CT is not always essential when clinical and basic radiological findings are concordant and that definitive one-stage surgery should be considered in carefully selected patients when residual gallstones or multiple fistulae are present.

Strengths and limitations

The strength of this report lies in the rare presentation of dual fistulae managed successfully with a one-stage approach in a high-risk patient without CT. Limitations include the single-center experience, the absence of recorded operative duration and estimated blood loss, and short follow-up (21 days), which precludes assessment of long-term biliary symptoms, fistula integrity, or late bile leak.

Conclusion

Gallstone ileus secondary to concomitant cholecystoduodenal and cholecystocolonic fistulae is rare. In carefully selected patients with imminent risk of further obstruction, a single-stage operation incorporating enterolithotomy, fenestrating partial cholecystectomy and primary fistula repair can be performed safely with good short-term outcomes, even without preoperative CT imaging. Longer-term follow-up data remain desirable.

Ethical approval

Not required for a case report in accordance with institutional policy.

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Sources of funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author contributions

M.M.: Conceptualization, data collection, writing – original draft, supervision. K.L.: Data collection, writing – review and editing. B.M.A.: Data collection, writing – review and editing. E.D.M.: Supervision, critical revision of the manuscript.

Conflicts of interest disclosure

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Research registration unique identifying number (UIN)

Not applicable.

Guarantor

Dr Mozamil Mohamed.

Provenance and peer review

Not applicable.

Data availability statement

All data generated or analysed during this study are included in this published article. Further de-identified clinical details are available from the corresponding author on reasonable request.

Declaration of AI Use

The authors used generative artificial intelligence tools solely for language editing and grammar correction. No AI tools were used for data generation, analysis, or interpretation. All content and clinical decisions remain the responsibility of the authors.