A 79-year-old female patient:
– Presented with abdominal pain, nausea, vomiting
– Previous history of cholecystitis and pancreatitis
– Laboratory findings:
*Elevated C-reactive protein and white blood cell levels
What do you see?
Pneumobilia (arrow)
Cholecystoduodenal fistula (red arrow)
Gastric (blue arrow) and duodenal (green arrow) distension
Gallstone located in the proximal jejunal segment (red arrows)
Gastric distension (blue arrows)
What is your diagnosis?
Gallstone ileus
Abdominal CT images obtained two years earlier show that the gallstone is in the gallbladder (arrows).
Teaching points:
* Gallstone ileus is a cause of mechanical small bowel obstruction that generally affects the elderly and has high mortality. It is a rare complication of chronic cholecystitis. It develops when a gallstone passes through a cholecystoenteric fistula leading to small bowel obstruction.
* Gallstones most commonly become impacted in the distal ileum.
* The classical imaging findings on abdominal radiographs form Rigler triad: pneumobilia, small bowel obstruction, and ectopic radio-opaque gallstone
* CT is the most frequently used imaging modality for the diagnosis as it demonstrates the rim-calcified or total-calcified ectopic gallstone, abnormal gallbladder with air collection, presence of air-fluid level, biliary-enteric fistula, and transition point of small bowel obstruction. However, only a minority of gallstones are calcified. Therefore, they may be overlooked in intestinal lumen, which may result in misdiagnosis. Multiplanar reformatted CT images can be helpful to locate the migration site of the ectopic stones.
* Treatment: Surgery with removal of gallbladder stone is the definitive treatment.
In our case, the patient underwent surgery. Enterotomy with gallstone removal was performed. According to the operation note, the gallstone was located in the jejunum 20 cm distal to the ligament of Treitz.
Gall stone ileus