A 72-year-old woman presents with abdominal distension, vomiting, and obstipation. She had recurrent biliary colic for years but no recent pain. Abdominal radiograph shows dilated small bowel loops, gas in the biliary tree, and a calcified shadow in the right iliac fossa. The most appropriate operative intervention is:

• A Enterolithotomy alone, leaving the cholecystoenteric fistula untouched ✓
• B One-stage cholecystectomy with fistula division and enterolithotomy
• C Right hemicolectomy with primary anastomosis
• D Colonoscopic extraction of the calculus

Explanation

The findings are Rigler's triad of gallstone ileus: small bowel obstruction, pneumobilia, and an ectopic calcified gallstone. Standard practice is simple enterolithotomy to relieve the obstruction, because dissection of an inflamed, contracted gallbladder adherent to the duodenum carries high morbidity in these elderly patients. Most fistulas close spontaneously; formal fistula repair is reserved for select cases and is not done routinely.

Reference: Bailey and Love's Short Practice of Surgery, 27th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.