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  • Case Study
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Diagnosis and treatment of a patient with gallstone ileus

Abstract

Background A 79-year-old white woman presented with upper abdominal pain. She had a history of rheumatoid arthritis since she was 19 years old, which was treated with prednisolone, leflunomide, diclofenac and pantoprazole. She also had factor VII deficiency. The patient had been hospitalized 2 months previously with sepsis presumed to be due to urinary infection, and was treated with antibiotics. Sonography at this time revealed a gallbladder with a monstrous thick wall and stones, and the first differential diagnosis was cholecystitis. Cholecystectomy was planned after amelioration of the patient's general state, but her general state worsened.

Investigations Sonography, endoscopy of the upper and lower intestine, and CT scan.

Diagnosis Biliodigestive fistula and gallstone ileus.

Management Enterolithotomy, stenting, endoscopic retrograde cholangiopancreatography, and surgery.

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Figure 1: Duodenal 'ulcer' in the patient (black arrow).
Figure 2: CT of the upper abdomen showing air in the gallbladder (black arrow) and contrast medium flowing from the gallbladder into the duodenum (white arrow).
Figure 3: Endoscopic retrograde cholangiopancreagraphy of the patient.
Figure 4: CT of the lower abdomen showing the stone in the terminal ileum (white arrow).
Figure 5: Sonography of the small intestine.
Figure 6: Endoscopy of the duodenum of another patient with gallstone ileus showing a stone in the duodenum.

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Correspondence to Ina Zuber-Jerger.

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The authors declare no competing financial interests.

Glossary

CHOLECYSTITIS

Inflammation of the gallbladder

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY

Endoscopic technique of injecting contrast dye into the ampulla of Vater for radiologic visualization of the pancreatic and biliary ducts

LITHOTRIPTOR

An instrument that is used to catch stones in the common bile duct and destruct them in situ by mechanical compression

MISERERE

Bowel fluid

GALLSTONE ILEUS

When a gallstone migrates into the duodenum by penetration because of cholecystitis and blocks the intestine (normally at Bauhin's valve)

ILEOCOLONOSCOPY

Endoscopic procedure inspecting the terminal ileum, Bauhin's valve, the colon and the rectum

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Zuber-Jerger, I., Kullmann, F., Schneidewind, A. et al. Diagnosis and treatment of a patient with gallstone ileus. Nat Rev Gastroenterol Hepatol 2, 331–335 (2005). https://doi.org/10.1038/ncpgasthep0211

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  • DOI: https://doi.org/10.1038/ncpgasthep0211

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