"An unusual cause of small bowel obstruction: Gallstone ileus, a rare presentation of chronic gallstone disease".

Abstract

Introduction and importance: Gallstone ileus is a rare cause of mechanical small bowel obstruction, accounting for 1-4 % of cases and is most common in elderly females. It arises from the passage of a large gallstone through a cholecysto-enteric fistula into the intestinal lumen, where it lodges-typically in the terminal ileum-causing obstruction.

Presentation of case: A 52-year-old male presented with four days of abdominal pain, vomiting, distension, and constipation. He had a 22-year history of gallstones but no prior biliary symptoms. Imaging revealed small bowel obstruction with a cholecysto-duodenal fistula and a 3.5 cm gallstone impacted in the ileum. He underwent successful open enterolithotomy with an uneventful recovery.

Clinical discussion: Gallstone ileus commonly affects elderly females due to higher prevalence of gallstones and chronic cholecystitis. Risk factors for gallstones include obesity, diabetes, and smoking, none of which were present in this patient. Delayed presentation may be attributed to low awareness, limited access to care, and absence of prior symptoms. CT abdomen is the gold standard for diagnosing gallstone ileus, surpassing X-ray and ultrasound, revealing Rigler's triad-pneumobilia, ectopic stone, and obstruction. Surgical options include enterolithotomy alone or combined with cholecystectomy and fistula repair. In stable patients, enterolithotomy alone is preferred due to lower morbidity.

Conclusion: Gallstone ileus should be suspected in bowel obstruction even in atypical populations. Prompt diagnosis and minimally invasive surgical management can ensure good outcomes.