An 82-year-old woman arrives at the emergency department accompanied by her daughter. She … — USMLE Step 2 CK

An $82$ -year-old woman arrives at the emergency department accompanied by her daughter. She reports a $3$ -day history of progressively worsening, colicky abdominal pain accompanied by multiple episodes of dark green vomiting. The patient mentions she has not passed gas or had a bowel movement for the past $48$ hours. Her past medical history includes hypertension, diet-controlled type 2 diabetes mellitus, and osteoarthritis. Ten years ago, she experienced recurrent episodes of severe postprandial right upper quadrant pain but elected not to undergo surgical intervention. She has never had abdominal or pelvic surgery.

Her temperature is $37.8^\circ\text{C}$ ( $100.0^\circ\text{F}$ ), blood pressure is $112/68\text{ mm Hg}$ , pulse is $105/\text{min}$ , and respiratory rate is $18/\text{min}$ . Physical examination reveals dry oral mucosa. The abdomen is markedly distended and tympanic to percussion. Auscultation reveals high-pitched, tinkling bowel sounds. There is mild, diffuse abdominal tenderness but no rigidity, guarding, or rebound tenderness. Laboratory studies show a leukocyte count of $11,200/\text{mm}^3$ .

A plain radiograph of the abdomen reveals prominently dilated loops of small bowel with multiple air-fluid levels. Additionally, a branching radiolucency is visible overlying the central liver shadow, and a $3.0\text{ cm}$ opaque calcified density is noted in the right lower quadrant.

Which of the following is the most appropriate next step in management?

Surgical enterolithotomyCevap
B
Nasogastric tube decompression and clinical observation
C
Cholecystectomy with concurrent fistula repair
D
Intravenous administration of broad-spectrum antibiotics
E
Endoscopic retrograde cholangiopancreatography

Cevap

Surgical enterolithotomy is the correct intervention, focusing strictly on relieving the mechanical bowel obstruction without adding the morbidity of a concurrent cholecystectomy.

The correct answer is surgical enterolithotomy. This patient presents with a classic case of gallstone ileus, a mechanical small bowel obstruction caused by a large gallstone that has eroded into the intestinal tract, usually via a cholecystoduodenal fistula. The stone typically travels distally and impacts at the narrowest portion of the small bowel, the terminal ileum (indicated by the right lower quadrant calcification). The radiograph demonstrates Rigler's triad: small bowel obstruction, pneumobilia (branching radiolucency over the liver), and an ectopic gallstone. Because stones large enough to cause ileus rarely pass spontaneously, definitive surgical intervention is required. In elderly or medically compromised patients, the standard of care is an isolated enterolithotomy (opening the bowel to extract the stone) to resolve the acute obstruction. Performing a simultaneous cholecystectomy and fistula repair (a one-stage procedure) is associated with significantly higher morbidity and mortality and should be avoided in the acute setting.

Adım Adım Çözüm

Analyze the patient's symptoms and physical exam.

The patient exhibits classic signs of a small bowel obstruction (SBO), including colicky abdominal pain, bilious vomiting, obstipation, abdominal distension, and high-pitched bowel sounds.

Identifying the clinical syndrome narrows the differential diagnosis to causes of mechanical bowel obstruction.

Interpret the abdominal radiograph findings.

The radiograph shows dilated small bowel loops (SBO), a branching radiolucency over the liver (pneumobilia), and a calcified density in the RLQ (ectopic gallstone). This combination is known as Rigler's triad.

Rigler's triad definitively diagnoses gallstone ileus, which occurs when a large gallstone erodes through the gallbladder wall into the duodenum and impacts in the distal ileum.

Determine the most appropriate management for the established diagnosis.

The patient requires surgical removal of the impacted stone via enterolithotomy.

Gallstones large enough to cause ileus (typically >2.5 cm) will not pass spontaneously. To minimize surgical morbidity in an elderly patient, a simple enterolithotomy is strongly preferred over a complex one-stage procedure that includes fistula repair.

Anahtar Kavram

The diagnosis of gallstone ileus relies on recognizing Rigler's triad (small bowel obstruction, pneumobilia, and an ectopic gallstone), and the acute management involves surgical enterolithotomy alone to relieve the obstruction.

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