Gallstone Ileus Presenting as Small Bowel Obstruction in an Elderly Patient: Diagnostic Approach and Surgical Management

Background: Gallstone ileus is an uncommon cause of mechanical intestinal obstruction that predominantly affects older adults. It results from migration of a gallstone through a biliary–enteric fistula, most commonly a cholecystoduodenal fistula. Methods: An 84-year-old woman with hypertension and hypothyroidism presented with a four-day history of right upper quadrant abdominal pain, nausea, and vomiting. Laboratory investigations showed a marked inflammatory response and severe renal dysfunction with a substantial reversible acute component, most likely related to volume depletion and reduced renal perfusion. Computed tomography demonstrated an ectopic gallstone impacted in the distal small bowel, proximal bowel dilatation, pneumobilia, and a cholecystoduodenal fistula. Emergency laparotomy confirmed gallstone ileus. After assessment of the operative risk and local anatomy, a one-stage procedure was performed, comprising enterolithotomy, cholecystectomy, division of the fistula, and primary repair of the duodenal defect. Results: Postoperative management included continued monitoring of the admission renal dysfunction, together with treatment of postoperative tracheobronchitis, anemia, electrolyte disturbances, and transient elevation in pancreatic enzymes. These abnormalities were managed with supportive and multidisciplinary care. Renal function, inflammatory markers, and electrolyte concentrations improved substantially before discharge. Pancreatic amylase returned to its reference interval, whereas total α-amylase was below its stated reference interval at discharge, although anemia persisted. The patient was discharged in satisfactory condition on postoperative day 13. Conclusions: Computed tomography enabled preoperative diagnosis and characterization of the cholecystoduodenal fistula. Although a one-stage operation was feasible in this patient, this single outcome does not establish its superiority. Surgical management should be individualized according to the patient’s physiological condition, comorbidities, and intraoperative findings.