Gallstone ileus
ICD-10 K56.3 is a billable code used to indicate a diagnosis of gallstone ileus.
Gallstone ileus is a rare but serious complication of cholelithiasis, where a gallstone obstructs the intestinal lumen, typically in the small intestine. This condition arises when a gallstone erodes through the gallbladder wall into the gastrointestinal tract, often leading to obstruction at the ileum. Clinically, patients may present with symptoms such as abdominal pain, nausea, vomiting, and signs of bowel obstruction, including distension and constipation. The anatomy involved primarily includes the gallbladder, small intestine, and occasionally the large intestine, depending on the location of the obstruction. Disease progression can lead to bowel ischemia, perforation, and peritonitis if not promptly diagnosed and treated. Diagnostic considerations include imaging studies such as abdominal X-rays, CT scans, or ultrasound, which can reveal the presence of air in the biliary tree (pneumobilia) and the obstructing gallstone. Early recognition and surgical intervention are crucial to prevent complications and improve patient outcomes.
Standard ICD-10-CM documentation requirements apply
Various clinical presentations within this specialty area
Follow specialty-specific billing guidelines
Standard ICD-10-CM documentation requirements apply
Various clinical presentations within this specialty area
Follow specialty-specific billing guidelines
K56.3 specifically covers gallstone ileus, characterized by intestinal obstruction caused by a gallstone. It is important to differentiate this from other types of ileus or intestinal obstruction, which may have different underlying causes.
K56.3 should be used when the obstruction is specifically due to a gallstone. If the obstruction is due to other causes, such as adhesions or hernias, then other codes like K56.0 or K56.2 should be utilized.
Documentation should include clinical findings, imaging results showing the obstructing gallstone, and any surgical reports if applicable. Clear notes on the patient's symptoms and the treatment plan are also essential.
