Gallstone Ileus Caused by A Cholecystoduodenal Fistula in A 58-Year-Old Man: A Case Report

Abstract

Background: Gallstone ileus is an uncommon mechanical bowel obstruction caused by migration and impaction of a gallstone through a bilioenteric fistula. Its nonspecific presentation may delay diagnosis, whereas computed tomography can demonstrate the characteristic combination of intestinal obstruction, pneumobilia, and an ectopic gallstone.

Case presentation: A 58-year-old man with no reported chronic diseases presented with six days of colicky mesogastric and hypogastric pain, nausea, gastrobiliary vomiting, progressive abdominal distension, and absence of stool and flatus. Plain abdominal radiographs showed dilated small-bowel loops and multiple air-fluid levels. After 24 hours without improvement under initial conservative management, computed tomography revealed pneumobilia, gastric and small-bowel dilatation, and a 25-mm ectopic stone in the ileum, consistent with Rigler’s triad. Emergency exploratory laparotomy identified a cholecystoduodenal fistula and a 3-cm gallstone impacted 25 cm proximal to the ileocecal valve. Enterolithotomy and primary enterorrhaphy were performed; the gallbladder and fistula were not addressed during the index operation. The patient resumed oral intake after four postoperative days and was discharged on postoperative day six without complications. Subsequent follow-up was reported as favorable.

Conclusion: In patients with otherwise unexplained small-bowel obstruction, early recognition of Rigler’s triad can establish the diagnosis of gallstone ileus. Enterolithotomy alone is a reasonable obstruction-relieving strategy when a longer one-stage biliary procedure is not considered appropriate; definitive management should be individualized according to physiologic reserve, intraoperative findings, and biliary symptoms.