Gallstone ileus

Case contributed by Dr Hani Makky Al Salam

Presentation

Abdominal pain, distention, nausea and vomiting. History of laparotomy and incisional hernia repair.

Patient Data

Age: 70 years
Gender: Male
X-ray

Erect and supine abdominal x-rays demonstrate a number of prominent air-fluid levels located within dilated loops of small bowel. In addition, branching lucency is visible near the liver hilum. A faint rounded calcified density is visible to the left of the midline, projecting to the side of the L3/4 disc space and above the iliac crest.

Annotated image

Branching lucency in the right upper quadrant (green arrows) and a faint peripherally calcified opacity to the left of the midline (blue arrows) are visible, in addition to multiple air fluid levels (orange lines). 

The patient went on to have the inevitable CT scan, although the correct diagnosis had already been made by the radiologist. 

CT

A 3 cm calcified gallstone is seen at the point of transition between dilated fluid filled proximal small bowel, and collapsed distal small bowel. 

Gas is confirmed to be present at the liver hilum, confined to the biliary tree. 

Annotated image

Calcified gallstone (blue dotted line) is the cause of the small bowel obstruction, with markedly dilated loops extending proximally.  Pneumobilia is evident at the hepatic hilum (green arrows). 

There is evidence of a previous abdominal hernia repair (yellow arrows). 

Case Discussion

Abdominal films are often no longer obtained in the setting of acute abdominal pain, with most patients proceeding directly to CT. It is true that if the patient is unwell enough, plain films are unlikely to make a CT unnecessary. Even so, in this case, supine and abdominal films were sufficient to make the diagnosis. Although with the advance of cross-sectional imaging confidence in abdominal plain films has diminished, gallstone ileus remains a favorite case for oral exams. 

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