Dx: Gallstone ileus
Evaluation of the spiral CT scan revealed abnormal gas in the gallbladder fossa (FIGURE 1A), gas in the biliary tree, and distended loops of small bowel consistent with partial small bowel obstruction. A laminated calcified mass was present in the ileal lumen in the right iliac fossa (FIGURE 1B, arrow). These findings suggested gallstone ileus.1
Gallstone ileus is a rare complication of recurrent gallstones.2 It accounts for 1% to 4% of all cases of mechanical intestinal obstruction, but up to 25% of cases in patients older than age 65.2 The condition is more common in women2 and, if missed, is associated with a high degree of morbidity and mortality.3
Rule out other causes of right upper quadrant pain
The differential diagnosis for gallstone ileus includes other causes of right upper quadrant pain.
Acute cholecystitis is characterized by abdominal pain in the right upper quadrant that extends to the shoulder. It can be visualized by sonography as a gallbladder with a thickened wall.4
Acute cholangitis typically presents with fever, right upper quadrant pain, and jaundice (Charcot’s triad).
Biliary colic is associated with right upper quadrant or epigastric pain that begins postprandially.
Hepatitis can be asymptomatic or the patient can have icterus with gastrointestinal symptoms, depending on the type of causative virus and phase of illness.
Also consider other potential causes of small bowel obstruction.
Gastric or duodenal ulcers usually present with painless bleeding and can be diagnosed with an upper endoscopy.4
Pancreatitis is characterized by high lipase levels and patients may describe the pain as feeling “like a belt around the upper abdomen.”4
Bowel ischemia is usually characterized by diffuse pain, diarrhea, and a positive lactate test.4