Gallstone ileus is an uncommon cause of mechanical small bowel obstruction that most often affects older adults with comorbid disease and may be difficult to diagnose because symptoms and laboratory findings are frequently nonspecific. We report the case of a 70-year-old man with hypertension, hypercholesterolemia, coronary artery disease, and gastroesophageal reflux disease who presented to the emergency department with progressive abdominal pain, distention, and recurrent non-bilious emesis after being discharged from another facility following symptomatic treatment. On examination, he had abdominal distention, decreased bowel sounds, diffuse tenderness, and signs of dehydration. Laboratory testing showed no leukocytosis, but lactate was mildly elevated. Computed tomography of the abdomen and pelvis demonstrated a small bowel obstruction caused by a 3 × 2 cm calcified intraluminal mass impacted at the ileocecal valve, consistent with gallstone ileus. Surgical consultation was obtained, and the patient underwent enterolithotomy, with removal of the obstructing gallstone and bowel decompression. Given his age, cardiovascular comorbidities, and elevated operative risk, cholecystectomy and fistula repair were deferred. His postoperative course was uncomplicated, and follow-up showed no recurrent symptoms, with spontaneous closure of the biliary-enteric fistula. This case underscores that gallstone ileus must remain an important diagnostic consideration in older adults presenting with bowel obstruction, even in the absence of known biliary disease. Early CT imaging is essential for timely diagnosis, and operative management should be tailored to the patient’s physiologic risk and overall surgical candidacy.
Segarra et al. (Sat,) studied this question.