A 70-year-old woman with a known history of gallstones presents with colicky abdominal pain, distension, and vomiting. Abdominal radiograph shows dilated small bowel loops, gas in the biliary tree, and a calcified opacity in the right iliac fossa. After resuscitation, the most appropriate operative step is:

• A Right hemicolectomy
• B One-stage enterolithotomy with fistula division and cholecystectomy
• C Emergency ERCP with stone extraction
• D Enterolithotomy through a proximal enterotomy ✓

Explanation

The Rigler triad of pneumobilia, small bowel obstruction, and an ectopic gallstone confirms gallstone ileus from a cholecystoduodenal fistula. In an elderly, often frail patient, enterolithotomy alone relieves the obstruction and carries the lowest morbidity; formal fistula repair with cholecystectomy in the same sitting significantly increases complications and is not routinely performed unless the gallbladder is gangrenous.

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.