Presentation
Patient with history of gallstones and type 2 diabetes presented with abdominal pain and absence of peristaltic sounds. Abdomen was painful during last three days. Patient mentioned vomiting yellowish, smelly contents during last night.
Patient Data
Distended loops of the small intestine are seen in the upper-left quadrant. The small intestine can easily be recognised by valvulae conniventes seen as dense circular lines passing through the whole lumen of the intestine. This is a sign of ileus.
Air is present in the gallbladder, which has a hyperaemic, swollen wall in close contact with the wall of the proximal duodenum, with suspected fistula. Fluid can be seen both around the gallbladder and the proximal duodenum. Dilated small intestine can be followed to the distal part of ileum, where an oval mass, i.e. impacted gallstone is found. Distally from the gallstone, the diameter of the intestine is normal in size.
Case Discussion
Gallstone ileus represents a mechanical obstruction of the small intestine by a gallstone, usually lodged in the proximal duodenum (Bouveret's syndrome) or in the terminal ileum. This is a complication of chronic cholecystitis when fistula between the gallbladder and duodenum is formed and a gallstone passes into the small intestine, and lodges in narrow parts of it. Less than 1% of cases of intestinal obstruction are caused by this mechanism.
CT is considered superior to plain abdominal films or US in the diagnosis of gallstone ileus cases, with a sensitivity of up to 93%. There are three radiographic signs pathognomonic of gallstone ileus:
- partial or complete intestinal obstruction
- pneumobilia or contrast material in the biliary tree
- an aberrant gallstone
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