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BMJ Case Reports 2012; doi:10.1136/bcr.12.2011.5387
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Gallstone ileus

  1. Pablo González Gutiérrez4
  1. 1Department of Internal Medicine, Hospital of Laredo, Laredo, Cantabria, Spain
  2. 2Department of Radiology, Hospital of Laredo, Laredo, Cantabria, Spain
  3. 3Department of Digestive Diseases, Hospital of Laredo, Laredo, Cantabria, Spain
  4. 4Department of Radiology Service, Hospital of Laredo, Laredo, Cantabria, Spain
  1. Correspondence to Dr Miguel F Carrascosa, miguel.carrascosa{at}scsalud.es

Description

The diagnosis of gallstone ileus entails a clinical challenge, especially in older patients in whom it may be easily overlooked.1 Herein, we report on a patient suffering from this condition who successfully recovered after surgery. A 65-year-old man presented to our emergency department with nausea, recurrent vomiting and colicky abdominal pain of 5 days’ duration. His medical history was relevant only for hypertension. Physical examination revealed a non-tender abdomen with active bowel sounds. Laboratory tests showed mild leukocytosis and severe, acute renal impairment. Abdominal radiograph demonstrated the presence of a round hyperdense mass with calcified margins in the right lower quadrant as well as enlarged loops of small bowel (figure 1). CT scan of the abdomen showed pneumobilia, a calcified intraluminal mass impacted in the terminal ileum and dilated upstream loops of small intestine (figure 2). These findings were diagnostic for gallstone ileus. On the same admission day, the patient was transferred to the operating room where a simple enterotomy and removal of the obstructing gallstone (5.2×3.6 cm) were performed. He made an uneventful recovery and was discharged 8 days after surgery. Gallstone ileus is an unusual complication of cholelithiasis that particularly affects older individuals and continues to be associated with high morbidity and mortality. It is caused by intestinal impactation of one or more gallstones after being passed through a biliary-enteric fistula. Most ectopic gallstones impact the ileum, which is the narrowest portion of the intestine. While gallstone ileus is responsible for only 1–4% of all cases of mechanical bowel obstruction,2 it causes up to 25% of non-strangulated small bowel obstruction in patients over age 65.3 Thus, gallstone ileus should always be high in the differential diagnosis when assessing an aged person with intestinal obstruction. The disorder, however, is often not considered since patients frequently deny a history of biliary disease. Strong clinical suspicion, timely use of combined diagnostic imaging modalities (mainly, abdominal plain film and CT scan), and early surgical intervention are of paramount importance to achieve a favourable outcome. Although the optimal therapeutic procedure for this entity is still a matter of discussion, enterolithotomy alone has been advocated as first-line approach for the majority of patients due to its lower morbidity, mortality, and reports on spontaneous fistula closure.2 3

Figure 1

Plain abdominal radiograph of a 65-year-old man showing signs of small-bowel mechanical obstruction caused by an ectopic gallstone (arrow).

Figure 2

CT scan of the abdomen revealing pneumobilia, a gallstone in the distal ileum (arrow) and small-bowel dilatation.

Learning points

  • Gallstone ileus is an unusual complication of cholelithiasis that particularly affects older individuals.

  • The disorder is often not considered since patients frequently deny a history of biliary disease.

  • Strong clinical suspicion, timely use of combined diagnostic imaging modalities (mainly, abdominal plain film and CT scan) and early surgical intervention are of paramount importance to achieve a favourable outcome.

Footnotes

  • Competing interests None.

  • Patient consent Obtained.

References

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