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Gallstone ileus

Case contributed by Ashesh Ishwarlal Ranchod
Diagnosis certain

Presentation

The patient presents with abdominal pain, vomiting and abdominal distension.

Patient Data

Age: 70 years
Gender: Female
x-ray

Features consistent with partial, small bowel obstruction demonstrated by distended, fluid-filled small bowel loops, with air-fluid levels. There is minimal proximal large bowel feacal loading. There is no free air. There is an age-appropriate appearance to the abdominal skeleton. There is an incidental central, metallic, sterilization clip.

ct

Features consistent with high-grade mechanical distal small-bowel obstruction secondary to gallstone ileus. A decompressed gallbladder demonstrates this with apparent wall thickening, and a cholecystoduodenal fistula at approximately D1 segment. There is a fluid-filled distended stomach with associated dilated fluid-filled small bowel loops. Distal ileal transitional zone with a large, lamellated, gallstone identified, measuring 23.2 mm in maximum diameter. There is no intrahepatic venous gas, no pneumobilia and no pneumatosis intestinalis.

There is evidence of a total hysterectomy. Solitary migrated central intrapelvic metallic sterilization clip. The adnexa appears normal. There is calcific and non calcific diverticulosis and no acute diverticulitis. The rest of the solid and hollow abdominal and pelvic viscera appear satisfactory. There are no occult intrahepatic, lymphatic, lung base or osseous metastases.

Annotated image

Selected annotated images demonstrating the cholecystoduodenal fistula and the lamellated Ileal gallstone.

Case Discussion

Typical findings of gallstone ileus on CT imaging with a cholecystoduodenal fistula, small bowel obstruction with a lamellated gallstone identified within the distal ileum. Rigler's triad was absent on plain films and additionally, there was no pneumobilia on CT imaging. The patient underwent surgical management which entailed a cholecystectomy, cholecystoduodenal fistula repair and an enterolithotomy, with an unremarkable post-operative recovery.

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