Case of the Month – February 2020
By Dr Bradley Wray
Patient presented to emergency with abdominal pain – ? diverticulitis ? bowel obstruction
Investigation with a CXR assessing for pneumoperitoneum associated with a perforation and a CT abdomen/pelvis.
The CT demonstrated a 31mm gallstone lodged in the small bowel associated with dilated loops of small bowel proximally in keeping with a small bowel obstruction. Gas in the gallbladder and biliary tree with a communication with the duodenum is consistent with a biliary-enteric fistula. There is a small volume of reactive free fluid in the abdomen but no signs of ischemia or perforation. Features are in keeping with a gallstone ileus.
Gallstone ileus is a rare but important cause of a mechanical small bowel obstruction. Repeated bouts of cholecystitis results in the formation of a fistula between the gallbladder and the adjacent bowel, commonly the duodenum or colon. If a gallstone is present, this can migrate through the fistula into the small bowel and eventually lodge in the bowel, causing a small bowel obstruction.
Treatment is usually surgical, involving removal of the stone (an enterolithotomy), removal of the gallbladder and repair of the fistula.