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Gallstone ileus: a not-so-rare cause of bowel obstruction in the elderly
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  1. Anthony O Noah,
  2. Ashar Wadoodi,
  3. Oliver Priest
  1. Department of Surgery, Maidstone & Tunbridge Wells NHS Trust, Maidstone, UK
  1. Correspondence to Dr Anthony O Noah, anthony.noah{at}gmail.com

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Description

A 92-year-old lady presented to the emergency department with a 2-day history of generalised colicky abdominal pain, diarrhoea and vomiting. Her medical history included gallstones and a right hemicolectomy for a benign caecal neoplasm in 2008. Abdominal palpation revealed suprapubic tenderness with no peritonism. Initial investigations included a white cell count of 12.5×109/l, C-reactive protein of 46 mg/l and a normal serum amylase of 76 U/dl. Plain abdominal x-ray was within normal limits. She was treated for gastroenteritis, but her condition deteriorated over the next 24 h with intractable vomiting, abdominal distension and ongoing pain. Repeat abdominal radiograph showed dilated stomach, dilated small bowel and an abnormal air pattern in the right upper quadrant. Contrast-enhanced CT scan revealed small bowel dilatation and a large concentric calcified object in the small bowel (figure 1) indicative of gallstone ileus. She underwent successful laparotomy and small bowel enterotomy to remove the stone (figure 2).

Figure 1

CT scan at the level of the pelvis showing a large calcific gallstone in the small bowel.

Figure 2

Postoperative image of the gallstone adjacent to a pen for scale comparison.

Gallstone ileus is a rare cause of bowel obstruction, accounting for 1–3% of all intestinal obstructions. It is more common in women and in the elderly, accounting for up to 25% of small bowel obstructions (SBO) in those over 65 years.1 Gallstone ileus occurs when a large gallstone (>2.5 cm diameter) erodes through a gangrenous gallbladder into the small bowel and impacts in the small-diameter distal ileum where peristalsis is less active. Plain x-ray is non-specific as only 10–20% of gallstones can be visualised with this modality. One study observed Rigler's triad of SBO, pneumobilia and ectopic gallstone within the bowel in 15% of x-rays and 77% of CT scans.2 Treatment is with surgical removal of the stone, combined with cholecystectomy and fistula repair in a number of highly selected cases.3

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Footnotes

  • Competing interests None.

  • Patient consent Obtained.