A 74-year-old woman presents with 2 days of colicky central abdominal pain, distension, and bilious vomiting. She has no previous surgery. Plain X-ray shows dilated small bowel loops, branching gas shadows in the right upper quadrant over the liver shadow, and a calcified rounded opacity in the right iliac fossa. After resuscitation, what is the appropriate operative management?
- A Enterolithotomy alone via a longitudinal enterotomy proximal to the stone ✓
- B Milking of the stone into the colon followed by closure
- C One-stage enterolithotomy with cholecystectomy and fistula repair
- D Right hemicolectomy with primary anastomosis
Correct answer: A. Enterolithotomy alone via a longitudinal enterotomy proximal to the stone
Explanation
The findings are the Rigler triad of gallstone ileus: small bowel dilation, pneumobilia, and an ectopic calcified stone. The stone impacts typically at the narrow terminal ileum through a cholecystoduodenal fistula. Standard practice is enterolithotomy alone, because the fistula frequently closes spontaneously and dissection in a densely inflamed right upper quadrant carries high morbidity in these elderly patients. Cholecystectomy and fistula division at the same sitting is reserved for selected fit patients.
Reference: Bailey and Love's Short Practice of Surgery, 27th ed.
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Written and medically reviewed by the StethoPrep medical team.