A 68-year-old woman comes to the emergency department due to a 2-day history of crampy abdominal pain and vomiting. The patient has had no hematemesis, melena, or hematochezia. She has a history of hypertension, type 2 diabetes mellitus, and coronary artery disease. Several months ago, the patient had an episode of acute calculous cholecystitis that was managed non-operatively. Physical examination shows a distended, tympanic abdomen with high-pitched bowel sounds. Abdominal x-ray reveals air in the gallbladder and biliary tree. This patient's gallstone has most likely lodged in which of the following sites?

Question

A 68-year-old woman comes to the emergency department due to a 2-day history of crampy abdominal pain and vomiting.  The patient has had no hematemesis, melena, or hematochezia.  She has a history of hypertension, type 2 diabetes mellitus, and coronary artery disease.  Several months ago, the patient had an episode of acute calculous cholecystitis that was managed non-operatively.  Physical examination shows a distended, tympanic abdomen with high-pitched bowel sounds.  Abdominal x-ray reveals air in the gallbladder and biliary tree.  This patient's gallstone has most likely lodged in which of the following sites?

Quizplus · Accepted Answer

11ec160b_357c_1c53_9249_bbb14c715b38_MD0001_00 This patient likely has gallstone ileus, an uncommon complication of longstanding cholelithiasis that usually occurs in elderly women. A large (typically >2.5 cm) gallstone causes formation of a cholecystoenteric fistula between the gallbladder and adjoining gut (most often the duodenum) due to pressure necrosis and erosion of these tissues. Fistula formation allows passage of the gallstone into the small bowel, where it travels freely until it becomes trapped in the ileum, the narrowest portion of the intestine. Patients consequently develop symptoms/signs of small bowel obstruction, including abdominal pain/distension, nausea/vomiting, high-pitched (tinkling) bowel sounds, and tenderness to palpation. Abdominal x-ray may reveal dilated loops of bowel with air-fluid levels due to intestinal obstruction. Communication between the intestine and gallbladder may also allow gas to enter the biliary tree (pneumobilia). (Choice A) Obstruction of the common bile duct by a gallstone (choledocholithiasis) can lead to pancreatitis and/or cholangitis. Cholangitis typically presents with fever, right upper quadrant abdominal pain, and jaundice (Charcot triad). Pneumobilia and features of small bowel obstruction are not characteristic. (Choice B) Obstruction of the cystic duct by a gallstone may result in biliary colic or acute cholecystitis. Acute cholecystitis usually presents with fever, abdominal pain, leukocytosis, and an inspiratory pause during right upper quadrant palpation (Murphy sign). Pneumobilia and features of small bowel obstruction are not characteristic. (Choices C and E) The caliber of the duodenum and jejunum is typically sufficient to allow passage of larger gallstones that cause gallstone ileus. Educational objective: Gallstone ileus results from passage of a large gallstone through a cholecystenteric fistula into the small bowel, where it ultimately causes obstruction at the ileum. Patients typically present with symptoms/signs of small bowel obstruction, and an abdominal x-ray may reveal gas within the gallbladder and biliary tree. __________ References: Gallstone ileus: case report and literature review. (http://www.ncbi.nlm.nih.gov/pubmed/24023505)

A 68-Year-Old Woman Comes to the Emergency Department Due to a 2-Day