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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).
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
Competing interests None.
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