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Gallstone ileus is a rare (0.3-0.5%), but morbid complication of cholelithiasis. Incidence peaks between 65 and 75 years of age, and although rare in the general population, this complication accounts for 25 per cent of nonstrangulated bowel obstructions in patients greater than 65 years of age.1 An episode of acute cholecystitis with cholecyst-enteric fistula formation usually precedes gallstone ileus. Only a few cases have been reported in which gallstone ileus was encountered after cholecystectomy.
A 51-year-old Hispanic female underwent laparoscopic cholecystectomy for acute calculous cholecystitis. At the time of cholecystectomy she had no symptoms of bowel obstruction and was discharged on postoperative day 1 after a routine early recovery, including the passage of stool and tolerance of oral intake. On postoperative day 9 she returned, complaining of 6 days of nausea, vomiting, and abdominal pain. She reported five to six episodes of emesis daily and described the pain as diffuse, dull, intermittent, and of mild intensity. For the preceding 8 days she reported neither the passage of stool nor of flatus. She denied fever. Past medical history was significant for uncontrolled diabetes mellitus. In addition to cholecystectomy, past surgical history was significant for total abdominal hysterectomy.
Initial blood pressure was 100/56 mm Hg; pulse rate was 125; temperature was 36.9°C. Physical exam showed a soft, distended, and nontender abdomen with well-healing laparoscopic incisions. Rectal exam was positive for stool, and stool guaiac was negative. Initial laboratory values included: sodium 122 (136-145 mmol/L), potassium 3.7 (3.8-5.2 mmol/L), chloride 82 (98-107 mmol/L), bicarbonate 28.8 (21-32 mmol/L), urea nitrogen 36 (7-18 mg/dL), creatinine 1.1 (0.6-1.3 mg/dL), lactic acid 1.3 (0.4-2.0 mmol/L), hemoglobin 14.4 (14.0-18.0 g/dL), and white blood cell count 10.1 (2.4-12.0 K/mm3) with 80 per cent neutrophils. Computed tomography revealed high-grade small bowel obstruction with a transition point in the distal small intestine caused by a round, hypodense, and peripherally calcified 2.4 . 2.6 cm structure (Fig. 1). Persistent cholecyst-duodenal or cholecystogastric fistula was not seen...