Gallstone ileus, a case with appendicitis-like clinical presentation.

A 71-year-old man presented to the emergency department with acute onset of abdominal pain initially in the epigastrium and subsequently in the lower abdomen and nausea. Physical examination revealed stresses pain in right iliac fossa with associated defense. The patient had a past medical history of obesity and benign prostatic hyperplasia. His past surgical history included a total gastrectomy due to gastric adenocarcinoma. Laboratory values were remarkable for leukocytes 10,8 with a left shift. CT scans showed an important distension of small bowel loops with a large (3cm) calcified stone inside a loop located in pelves, findings consistent with gallstone ileus.

Gallstone ileus is a mechanical intestinal obstruction due to gallstone impaction within the gastrointestinal tract. Gallstone ileus is an uncommon presentation of gallstone disease (2). It has a propensity to affect females and the elderly, and it accounts for less than 1% of cases of intestinal obstruction (1). It occurs as a gallstone enters the small bowel through a biliary enteric fistula, with more than half of these being cholecystoduodenal fistulas. This fistula is created as the gallstone exerts pressure against the biliary wall, leading to necrosis. The symptoms and signs of gallstone ileus are mostly nonspecific, they differ depending on the site of gallstone impaction (2). Most commonly, gallstone ileus resembles small bowel obstruction of any cause(2). Computed tomography (CT) is considered superior to plain abdominal films or US in the diagnosis of gallstone ileus cases, with a sensitivity of up to 93% (1).Only a minority (1020%) of gallstones have sufficient calcium content to be visible on abdominal x-rays (2). Rigler’s triad, is a combination of radiological findings specific for bowel obstruction by gallstones. It includes mechanical obstruction, pneumobilia, and an ectopic gallstone within the bowel lumen. Our patient had all three Rigler’s findings in the CT examination. Surgery remains the gold standard treatment.

Gallstone ileus remains an important diagnosis as it results in significant morbility and mortality. This case emphasizes the importance in considering gallstone ileus as a cause for a mechanical bowel obstruction.

- Nuño-Guzmán CM, Marín-Contreras ME, Figueroa-Sánchez M, Corona J. Gallstone ileus, clinical presentation, diagnostic and treatment approach. World Journal of Gastrointestinal Surgery, 2016, 8(1): 65-76. - Chang L, Chang M,