Medically reviewed by Prof. Dr. Zahid Mahmood, MBBS, FCPS — General, Laparoscopic & Laser Surgeon, Lahore.
Gallstone ileus is a rare but serious form of mechanical bowel obstruction. A large gallstone passes from the gallbladder into the intestine through an abnormal connection, then becomes stuck—most often in the lower small bowel.
Despite its name, this is not a simple slowing of the bowel. It is a physical blockage that usually requires urgent hospital treatment and surgery. It occurs mainly in older adults with long-standing gallstones and may cause intermittent symptoms before complete obstruction develops.
How does a gallstone enter the intestine?
Repeated gallbladder inflammation can make the gallbladder adhere to the nearby duodenum or another part of the digestive tract. Pressure from a large stone and chronic inflammation gradually erode the walls, forming a passage called a cholecystoenteric fistula.
The stone then enters the bowel. Smaller stones often pass naturally, but a stone larger than about 2–2.5 cm may become impacted. The terminal ileum near the junction with the large intestine is the commonest site because its lumen is relatively narrow.
Who is at risk?
Gallstone ileus is uncommon, but risk is higher in:
- Older adults, particularly women
- People with long-standing or recurrent gallstone disease
- Patients with previous attacks of acute cholecystitis
- Those with large gallstones
- People with a narrowed bowel from diverticular disease, inflammation, previous surgery or tumour
Many affected patients also have heart, lung, kidney or metabolic illnesses that increase the risks of dehydration, obstruction and emergency surgery.
Symptoms of gallstone ileus
Typical symptoms of bowel obstruction include:
- Cramping or persistent abdominal pain
- Progressive abdominal swelling
- Nausea and repeated vomiting
- Inability to pass stool or wind
- Loss of appetite and dehydration
- Weakness, dizziness or reduced urine output
Symptoms can come and go as the stone tumbles through the intestine, temporarily blocking at different points. A patient may feel briefly better before the obstruction returns. This intermittent pattern can delay diagnosis.
When is it an emergency?
Gallstone ileus is an emergency. Seek immediate hospital care for abdominal pain and swelling with repeated vomiting or inability to pass stool or wind.
Call emergency services for:
- Severe, constant or rapidly worsening abdominal pain
- Fainting, confusion, extreme weakness or drowsiness
- Fever, rapid heartbeat or breathing difficulty
- Very low urine output or severe dehydration
- A rigid abdomen or pain with the slightest movement
- Blood in vomit or stool
These may indicate strangulation, bowel ischaemia, perforation, peritonitis or sepsis.
What is Bouveret syndrome?
Bouveret syndrome is a rare form of gallstone ileus in which a stone becomes stuck in the duodenum or near the stomach outlet. Instead of lower intestinal obstruction, it causes gastric outlet obstruction with persistent vomiting, early fullness, upper-abdominal pain and inability to tolerate food.
Endoscopic fragmentation or removal may be attempted in selected cases, but many patients still require surgery.
How is gallstone ileus diagnosed?
The initial assessment checks hydration, pulse, blood pressure, temperature, abdominal swelling, tenderness and bowel sounds. Blood tests evaluate anaemia, infection, kidney function, electrolytes, liver tests, clotting and lactate when bowel ischaemia is suspected.
Laboratory results are often non-specific. Normal liver tests do not exclude gallstone ileus because the stone has usually left the biliary system and entered the bowel.
CT scan
CT of the abdomen and pelvis is the most useful investigation. It can show:
- Dilated bowel above the obstruction and collapsed bowel beyond it
- An ectopic gallstone inside the intestine
- Air within the bile ducts or gallbladder, called pneumobilia
- An abnormal, inflamed or contracted gallbladder
- The fistula between the gallbladder and bowel
- Bowel-wall damage, perforation or another obstructing stone
The classic combination of bowel obstruction, pneumobilia and an ectopic gallstone is called Rigler’s triad. All three features are not always visible. Some cholesterol stones contain little calcium and can be difficult to distinguish from bowel contents, so the scan must be interpreted in its full clinical context.
Do ultrasound and X-ray help?
Plain abdominal X-rays may show obstruction, air in the biliary tree and a calcified stone, but many gallstones are not visible on X-ray. Ultrasound can show gallbladder abnormalities and pneumobilia, yet bowel gas often limits the examination. CT is generally more sensitive and better for surgical planning.
Initial treatment
Before surgery, the team stabilises the patient:
- Temporary fasting
- Intravenous fluids and correction of salts
- A nasogastric tube to drain accumulated stomach contents when required
- Pain relief and anti-sickness medicine
- Antibiotics if perforation, infection or sepsis is suspected
- Blood-clot prevention and treatment of heart, lung or kidney problems
Resuscitation is important, but it should not cause an unsafe delay when the bowel may be losing its blood supply.
Enterolithotomy: removing the obstructing stone
The usual operation is an enterolithotomy. The surgeon finds the obstructing stone, gently moves it to healthier bowel when possible, makes a small opening, removes the stone and closes the intestine.
The entire bowel is inspected for additional stones and for areas of injury. If the bowel around the impaction is dead, perforated or severely damaged, that segment must be removed and the healthy ends joined. A stoma is occasionally necessary if joining the bowel is unsafe.
Open or laparoscopic surgery?
Enterolithotomy can be performed through an open incision or, in selected stable patients and experienced centres, with laparoscopic assistance. The approach depends on bowel distension, stone location, previous operations, medical fitness and the surgeon’s expertise.
A keyhole approach may reduce wound size, but severely distended bowel can limit visibility and increase the risk of injury. Conversion to open surgery is a safety decision.
Should the gallbladder and fistula be treated at the same operation?
This decision is individualised. Most patients are older, dehydrated and medically fragile. For them, stone removal alone is commonly preferred because it relieves the life-threatening obstruction with a shorter operation.
A one-stage procedure combines enterolithotomy with gallbladder removal and fistula repair. It may be considered in a carefully selected, stable, lower-risk patient when the local inflammation and anatomy allow safe repair. It is a larger operation with greater physiological stress.
Delayed gallbladder surgery can be considered after recovery if the patient has persistent biliary symptoms, residual stones, recurrent infection or another specific concern. Many fistulas close naturally and many older patients never require further biliary surgery.
Can gallstone ileus be treated without surgery?
Established small-bowel obstruction from a large gallstone rarely resolves reliably without intervention. Waiting risks pressure injury, perforation, dehydration and sepsis.
Endoscopic extraction or fragmentation is sometimes possible for stones in the stomach, duodenum or colon, particularly in patients at very high surgical risk. Success depends on stone size and location, and fragments can migrate and obstruct further downstream. Surgery remains the standard treatment for most impacted small-bowel stones.
Possible complications
Complications of the disease include:
- Bowel ischaemia, pressure necrosis or perforation
- Peritonitis and sepsis
- Severe dehydration, electrolyte disturbance and kidney injury
- Aspiration pneumonia after vomiting
- Recurrent obstruction from a second stone
Possible postoperative complications include chest infection, blood clots, wound or abdominal infection, bowel leakage, prolonged ileus, heart or kidney complications and recurrent gallstone ileus.
Recovery after surgery
Recovery varies according to age, medical fitness, bowel damage and whether resection was required. Intravenous fluids and the nasogastric tube continue until bowel function returns. Drinking and eating are restarted gradually.
Early sitting, walking, breathing exercises and blood-clot prevention are important. Older or frail patients may need physiotherapy, nutritional support and rehabilitation before returning home.
Warning signs after discharge
Seek urgent medical advice for:
- Increasing abdominal pain or swelling
- Repeated vomiting or inability to pass stool or wind
- Fever, chills, confusion or fainting
- Redness, pus or separation of the surgical wound
- New jaundice
- Breathing difficulty, chest pain or a painful swollen leg
Can gallstone ileus recur?
Yes, although recurrence is uncommon. A second stone left in the bowel or gallbladder can cause another obstruction. Recurrence often occurs within the first weeks or months, which is why the surgeon examines the bowel during the operation and reviews the remaining biliary disease after recovery.
Can gallstone ileus be prevented?
Timely assessment and treatment of symptomatic gallstones and repeated acute cholecystitis may prevent the chronic inflammation that creates a fistula. Once a fistula and large migrated stone exist, diet or medicine cannot reverse the mechanical problem.
Common questions
Is gallstone ileus the same as paralytic ileus?
No. Paralytic ileus is failure of bowel movement without a physical blockage. Gallstone ileus is a mechanical obstruction caused by an impacted stone.
Can it occur without previous gallstone symptoms?
Yes. Some patients do not recall typical biliary pain or cholecystitis, and the first presentation may be bowel obstruction.
Why are symptoms sometimes intermittent?
The stone may tumble along the bowel and temporarily dislodge before becoming firmly impacted at a narrower site.
Does every patient need the gallbladder removed?
No. The immediate priority is relieving obstruction. Gallbladder removal and fistula repair depend on fitness, ongoing symptoms, residual stones and operative risk.
Can a CT scan miss the stone?
Yes. Some stones contain little calcium and blend with intestinal contents. The radiologist also looks for the transition point, pneumobilia and an abnormal gallbladder or fistula.
Is gallstone ileus dangerous?
Yes. It mainly affects older patients, diagnosis may be delayed, and obstruction can cause perforation or sepsis. Prompt resuscitation and surgical review improve outcomes.
Key message
Gallstone ileus is a rare mechanical bowel obstruction caused by a gallstone that has entered the intestine through an abnormal gallbladder–bowel connection. Intermittent pain can delay recognition, but progressive swelling, vomiting and inability to pass stool or wind require emergency care. CT confirms the diagnosis, and urgent stone removal is the main treatment.
Medical references
- O’Connell PR, McCaskie AW, Sayers RD, editors. Bailey & Love’s Short Practice of Surgery. 28th ed. Chapter 71: The gallbladder and bile ducts, pp. 1248–1249.
- Turner AR, Sharma B, Mukherjee S. Gallstone Ileus. StatPearls. Updated September 2022; StatPearls Publishing, 2026.
- Ravikumar R, Williams JG. The operative management of gallstone ileus. Ann R Coll Surg Engl. 2010;92:279–281.
- The Rolling Stones: A Systematic Review and Meta-Analysis of the Management of Gallstone Ileus. Chirurgia. 2024;119:483–514.
This article provides general education and does not replace an examination or individual medical advice. Gallstone ileus is an emergency—seek immediate care for abdominal swelling and pain with repeated vomiting or inability to pass stool or wind.