Non-typical gallstone ileus: case report

Gallstone ileus (GI) is a complication of gallstone disease causing mechanical intestinal obstruction due to impaction of gallstone in the gastrointestinal tract. It accounts for less than 1-4% of the cases. It is more common among elderly female. Nowadays diagnosis of GI became more reliable and easier using radiological modalities such as abdominal CT/MRI scanning although still the mortality and morbidity considered to be high in such diagnosis. This is a case of gallstone ileus in a 73-year-old woman. Initially, plain X-ray showed signs of intestinal obstruction with large radiopaque shadows seen in right upper and lower quadrant of the abdomen. The diagnosis was made by MDCT scan which showed unfamiliar findings that are: unusual stone location that impacted in the jejunum, incomplete Rigler's triad as there was no pneumobilia and a 2.6 cm ectopic stone that appeared to be larger postoperatively. Patient underwent urgent laparotomy with enterotomy where a 4 cm gallstone was removed and intraoperative exploration for the rest of the bowel revealed another stone in the sigmoid colon that was initially detected by MDCT which milked toward the rectum. Post-operative course was uneventful. Abdominal X-ray can be used a preliminary tool for intestinal obstruction in general. Although abdominal CT scan is the investigation of choice to diagnose gallstone ileus, accurate size and number still under debate. Pneumobilia is not a common finding and Rigler’s triad advised to be revised. Intraoperative exploration is necessary to rule out other stones