DESCRIPTION

An 88-year-old woman presented with abdominal pain with an acute onset. She located the pain as being just below her umbilicus. The pain had a colic character and was accompanied by nausea and vomiting. There was no history of abnormal stools The patient underwent surgery 30 years earlier because of peritonitis, which resulted in possible Crohn of the small intestine as diagnosis. Furthermore, she was healthy and not using any medicine.

Clinical examination was not conclusive for peritonitis or perforation.

An x ray of her abdomen (fig 1) revealed a small intestine ileus and air in the gallbladder and also air in the cystic duct and radices. These findings of air in the gallbladder and radices were confirmed by ultrasound. Ultrasound did not reveal a gallstone in the gallbladder or cystic duct, and there were no signs of free fluid. The finding of air in the cystic duct and gallbladder is a sign of gallstone ileus.

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Figure 1

x Ray of the patient’s abdomen. The white arrow indicates the gall bladder; black arrows indicate the cystic duct and radices.

This patient was operated on, and during laparoscopic surgery the gallbladder was found to be macroscopically normal. The small intestine was infiltrated without dilatation. This segment also showed some fatty overgrowth associated with Crohn disease. After the infiltrated segment, an intraluminal mobile mass was found. This was removed and turned out to be the gallstone, 3 cm in diameter, which had been causing the current complaints.

After the removal of the stone, the patient recovered within a few days.

Pneumobilia due to gallstones has so far only been reported in case reports, so an exact prevalence is hard to establish.1^,2