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Difficulty: HardGastrointestinal and Abdominal Surgery

A 78-year-old woman is evaluated in the emergency department for a 3-day history of progressively worsening abdominal distension, nausea, and vomiting of brown, foul-smelling fluid. She has not had a bowel movement or passed flatus for 48 hours. Her medical history includes hypertension, diet-controlled type 2 diabetes mellitus, and multiple episodes of right upper quadrant pain after meals over the past year. Her temperature is 37.8°C (100.0°F), blood pressure is 105/65 mmHg, pulse is 112/min, and respirations are 20/min. Physical examination shows a significantly distended, tympanitic abdomen with high-pitched, tinkling bowel sounds. There is diffuse tenderness to palpation but no guarding or rebound tenderness.

Laboratory studies reveal:
TestResult
Leukocyte count11,500/mm³
Sodium132 mEq/L
Potassium3.1 mEq/L
Blood urea nitrogen42 mg/dL
Creatinine1.6 mg/dL

A non-contrast computed tomography scan of the abdomen demonstrates dilated small bowel loops up to the distal ileum, air in the biliary tree, and a 3.5-cm radiopaque structure in the right lower quadrant. Which of the following is the most appropriate next step in management?

  1. Exploratory laparotomy with enterolithotomyAnswer
  2. B
    Exploratory laparotomy with enterolithotomy, cholecystectomy, and fistula repair
  3. C
    Nasogastric tube decompression and serial abdominal examinations
  4. D
    Administration of oral water-soluble contrast medium
  5. E
    Endoscopic retrograde cholangiopancreatography

Answer

Exploratory laparotomy with enterolithotomy
This patient's clinical presentation and imaging findings (pneumobilia, small bowel obstruction, and an ectopic radiopaque stone in the right lower quadrant) are classic for gallstone ileus (Rigler's triad). This condition occurs when a large gallstone erodes through the gallbladder wall into the adjacent duodenum, creating a cholecystoduodenal fistula. The stone travels through the small intestine and typically impacts at the narrowest point, the terminal ileum, causing a mechanical obstruction. The most appropriate management is emergent exploratory laparotomy with enterolithotomy (surgical extraction of the stone) to relieve the obstruction. A one-stage procedure including cholecystectomy and fistula repair is generally avoided in the acute setting due to a significantly higher mortality rate, especially in elderly patients with multiple comorbidities.

Step-by-Step Solution

1
Identify the diagnosis based on the clinical presentation and imaging findings.
The patient has gallstone ileus, characterized by a mechanical small bowel obstruction, pneumobilia, and an ectopic gallstone (Rigler's triad).
The CT scan shows dilated small bowel, air in the biliary tree, and a 3.5-cm radiopaque mass in the right lower quadrant, which is diagnostic for a gallstone impacted at the terminal ileum.
2
Determine the appropriate surgical management.
The treatment of choice is enterolithotomy alone.
The immediate life-saving goal is to relieve the bowel obstruction. A one-stage procedure (including cholecystectomy and fistula repair) carries a very high mortality rate in elderly, frail patients and should only be performed in highly selected, stable patients.

Key Concept

Gallstone ileus diagnosis and surgical management
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Topics

Gastrointestinal and Abdominal Surgery

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