A 76-year-old woman is brought to the emergency department from her assisted living facili… — USMLE Step 2 CK

A $76$ -year-old woman is brought to the emergency department from her assisted living facility due to a $4$ -day history of worsening, colicky abdominal pain, nausea, and frequent bilious vomiting. She has not passed flatus or stool for the past $2$ days. Her medical history includes type 2 diabetes mellitus, hypertension, and episodic right upper quadrant abdominal pain for which she declined surgery several years ago.

Her temperature is $37.8^\circ\text{C}$ ( $100.0^\circ\text{F}$ ), pulse is $102/\text{min}$ , respirations are $18/\text{min}$ , and blood pressure is $110/70\text{ mm Hg}$ . On physical examination, the abdomen is distended and tympanitic with high-pitched, hyperactive bowel sounds. There is mild, diffuse tenderness without guarding or rebound.

An abdominal computed tomography scan with intravenous contrast reveals dilated loops of small bowel with a transition point in the right lower quadrant. Air is visible within the biliary tree, and a $3.5\text{-cm}$ calcified intraluminal mass is identified near the ileocecal valve.

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

Immediate exploratory laparotomy with enterolithotomyCevap
B
Continued conservative management with nasogastric decompression
C
Endoscopic retrograde cholangiopancreatography
D
Urgent laparoscopic cholecystectomy
E
Diagnostic trial with a hyperosmolar water-soluble contrast agent

Cevap

Immediate exploratory laparotomy with enterolithotomy

The correct answer is immediate exploratory laparotomy with enterolithotomy. This patient's clinical presentation and imaging findings are classic for gallstone ileus, a mechanical small bowel obstruction caused by a large gallstone that has eroded through the gallbladder wall into the adjacent duodenum (forming a cholecystoduodenal fistula) and impacted in the distal ileum. The computed tomography scan demonstrates the classic Rigler triad: small bowel obstruction, pneumobilia (air in the biliary tree), and an ectopic calcified gallstone. Unlike uncomplicated adhesive small bowel obstructions, which may resolve with conservative management, gallstone ileus requires surgical intervention to relieve the obstruction. The definitive treatment is an exploratory laparotomy with a longitudinal enterotomy to extract the stone (enterolithotomy). Cholecystectomy and fistula repair are typically deferred in the acute setting, especially in elderly patients, due to high surgical morbidity.

Adım Adım Çözüm

Analyze the patient's clinical presentation and history.

The patient is an elderly woman presenting with symptoms of a small bowel obstruction (colicky pain, bilious vomiting, obstipation) and a history of untreated gallstone disease.

Identifying the clinical syndrome and relevant risk factors narrows the differential diagnosis.

Interpret the imaging findings provided in the vignette.

The CT scan shows a small bowel obstruction, pneumobilia (air in the biliary tree), and an ectopic calcified mass in the right lower quadrant.

These findings constitute Rigler triad, which is pathognomonic for gallstone ileus.

Determine the most appropriate definitive management for the diagnosis.

Surgical extraction of the impacted stone (enterolithotomy) is definitively required.

Unlike adhesive obstructions, this mechanical obstruction is caused by a large solid object that will not pass spontaneously. Concurrent gallbladder surgery is typically avoided acutely to minimize morbidity.

Anahtar Kavram

Gallstone ileus presents with the classic Rigler triad (small bowel obstruction, pneumobilia, and an ectopic gallstone) and requires prompt surgical intervention via exploratory laparotomy and enterolithotomy, rather than conservative management.

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