Gallstone ileus due to duodenal diverticulosis

Abstract

A 74-year-old man, with no notable medical history, presented at the emergency department with a 3-day history of cramping abdominal pain, bloating, and vomiting. The physical examination was notable for diffuse abdominal tenderness, tympany, and a negative Murphy´s sign. Laboratory studies showed an increased level of C-reactive protein (126 mg/L; reference range < 5 mg/L), a normal complete blood count, and normal levels of liver enzymes. Findings on computed tomography of the abdomen included the presence of gastric distension, a small-bowel obstruction with an endoluminal image suggestive of a gallstone at the transition zone, a normal-shaped gallbladder, no pneumobilia and a duodenal diverticulum (A). During exploratory surgery, the transition zone was observed in the small bowel. Following an unsuccessful attempt to break up the gallstone and facilitate its passage into the cecum, an enterolithotomy was performed to extract a large gallstone measuring five centimeters (B). A normal gallbladder without cholecystoduodenal fistula was found, and the diagnosis of gallstone ileus caused by an impaction of a duodenal gallstone was made. This diagnosis distinguishes itself from ordinary forms of gallstone ileus (cholecystoduodenal fistula with pneumobilia) as well as from “enterolith ileus” caused by bezoar impaction. Histopathological analysis of the resected mass also confirmed the presence of a gallstone. The patient recovered well postoperatively and at a follow-up visit 3 weeks later he remained well with no further abdominal symptoms.