Gallstone ileus

Case contributed by Dr Naim K

Presentation

Intestinal obstruction.

Patient Data

Age: 75 years
Gender: Male

Abdomen ultrasound

Ultrasound

Dilated small bowel loops are seen in the left lower abdominal region.

In the first two images, the liver shows homogenous parenchymal echotexture with multiple echogenic foci suspicious for intrahepatic biliary air.

The gallbladder appears contracted with a thickened wall and contains debris with multiple echogenic materials.

The common bile duct could not be visualized.

The rest of the examination is normal, apart from multiple simple renal cysts are seen bilaterally the largest on the right measured about six centimeters (images not included).

CT abdomen and pelvis with IV and oral contrast

CT

There is moderate dilatation of the jejunal loops with intraluminal two and a half centimeters lamellated partly calcified rounded density in the left upper quadrant with collapsed distal small bowel loop.

Pneumobilia is seen, with gas pockets in the gallbladder lumen and common bile duct.

A fistulous tract is seen between the gallbladder and the duodenum.

A small contrast collection is seen lateral to the first part of the duodenum, and also a small amount is seen in the large bowel and rectum indicating partial small bowel obstruction.

Findings are indicative of gallstone ileus.

Nasogastric tube tip is seen projected laterally to the duodenal wall for readjustment.

The previously seen simple renal cysts are seen again.

Mild prostatic enlargement with multiple calcific foci is noted.

Normal appearances of the liver, spleen, and pancreas.

Case Discussion

This 75-year-old gentleman presented through the emergency room with signs and symptoms of intestinal obstruction. Ultrasound of the abdomen was initially requested and showed echogenic foci causing acoustic posterior shadowing within the liver parenchyma, and the gallbladder with dilated small bowel loops in the upper abdomen. CT scan of the abdomen and pelvis were advised by the radiology department for further evaluation, and showed intraluminal calcified rounded density in the jejunum with air pockets involving the intrahepatic biliary tree, gallbladder lumen, and the common bile duct. The diagnosis of gallstone ileus was made.

In patients with gallstone ileus, the stone tends to be large, and typically seen in the right iliac fossa, but can be lodged elsewhere in the small bowel like the jejunum in this case. 

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