An elderly woman in her 90s was admitted with signs and symptoms suggestive of obstructive ileus: crampy abdominal pain, repeated episodes of vomiting and increased bowel sounds with tympanic sound on percussion. A plain film radiograph (Figure 1) and computed tomography scans (Figure 2) of her abdomen confirmed Rigler's triad: ectopic gallstone, pneumobilia and small-bowel dilation. This patient's gallstone (2.5 × 3.5 cm) was lodged in the jejunum. Because the patient had concurrent disorders and was a poor operative candidate, we chose a conservative approach to treatment. Unfortunately, the patient died.
Gallstone ileus is a rare complication of gallstone disease. A small-bowel obstruction results after 1 or more gallstones migrate through a cholecystoenteric fistula.1 Elderly women are more likely than men to experience this complication for unclear reasons. Among patients with comorbidities, gallstone ileus has a mortality rate of up to 18%.2 In patients at low operative risk, staged laparoscopic management of gallstone ileus and of the associated cholecystoenteric fistula gives good results. For the majority of patients, though, laparotomy is the treatment of choice.
Anastasios Koulaouzidis MD Department of Gastroenterology Warrington Hospital Warrington, UK John Moschos MD PhD Department of Gastroenterology General Army Hospital Thessaloniki, Greece Shivaram Bhat MB BCh Department of Internal Medicine Warrington Hospital Karthikeyan Gopal MBBS Department of Radiology Warrington Hospital Warrington, UK