Gallstone ileus

Case contributed by Dr Ahmed Aboughonaim

Presentation

Dull aching diffuse abdominal pain, vomiting, dehydration and electrolyte disturbances.

Patient Data

Age: 80 years
Gender: Male
CT

Abdomen

Oval shaped hyperdense stone is seen within the distal portion of the jejunum partially occluding the lumen with mild proximal jejunal dilatation reaching 3.7 cm. All bowel loops show average mural enhancement with no sign of complication or perforation. 

The gallbladder has an average size with associated mural edema. Also noted is a fistula tracking between the gallbladder neck and the first part of the duodenum.

An uncomplicated left inguinal hernia is seen transmitting part of the sigmoid colon. Multiple bilateral renal simple cortical cysts and uncomplicated diverticular disease are also noted.

CT

Annotated images

Green arrows point to the site of cholecystoduodenal fistula.

Case Discussion

The patient presented to the emergency department complaining of dull diffuse abdominal pain, distension and vomiting which raised clinical suspicion for bowel obstruction. By clinical examination, abdominal distension and a left inguinal hernia were detected. 

CT abdomen showed mechanical obstruction with the transitional zone at the distal jejunal bowel loops causing partial intestinal obstruction, the causative mechanical element is a large oval intra-luminal hyperdense stone measuring 7 cm. Also noted, normal mural enhancement of all bowel loops, no pneumoperitoneum, a left inguinal hernia containing portions of the sigmoid colon. Also evident was a tiny fistula tract connecting the gallbladder neck with the 1st part duodenum representing a cholecystoduodenal fistula.

All the CT signs suggest gallstone ileus causing mechanical obstruction. The stone reached the bowel lumen through the cholecystoduodenal fistula.

The patient entered the operating room 24 hours after the CT study; the operative data confirmed the radiological diagnosis of gallstone ileus. The surgeon removed the stone and performed a gastrojejunostomy.

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Case information

rID: 64787
Published: 11th Dec 2018
Last edited: 12th Dec 2018
Inclusion in quiz mode: Included
Institution: Faculty of Medicine Alexandria University

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