A 70-year-old woman presents with distension, vomiting, and absolute constipation. Plain abdominal radiograph shows dilated small bowel loops, gas in the biliary tree, and a calcified opacity in the right iliac fossa that changes position on serial films. The most appropriate initial surgical management is:

• A Cholecystectomy with closure of the cholecystoduodenal fistula and removal of the stone
• B Right hemicolectomy with ileotransverse anastomosis
• C Enterolithotomy through a separate enterotomy proximal to the impaction ✓
• D Percutaneous transhepatic extraction of the gallstone

Explanation

This is gallstone ileus with the classic Rigler triad: small bowel obstruction, pneumobilia, and an ectopic calcified gallstone. The stone typically enters the duodenum through a cholecystoduodenal fistula after a large gallstone erodes the gallbladder wall. The standard operation in an elderly, often frail patient is simple enterolithotomy to relieve the obstruction; addressing the fistula and performing cholecystectomy at the same sitting adds morbidity and 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.