A 70-year-old woman presents with 3 days of colicky abdominal pain, distension, and bilious vomiting. She is afebrile. Plain abdominal radiograph shows dilated small bowel loops, gas in the biliary tree, and a calcified opacity in the right iliac fossa that has changed position compared to a film taken two years ago. What is the most appropriate initial surgical approach?
- A Resuscitation followed by enterolithotomy through an antimesenteric incision proximal to the stone ✓
- B Emergency right hemicolectomy with removal of the stone
- C Cholecystectomy, fistula division, and enterolithotomy as a single procedure
- D Colonoscopic extraction of the stone after decompression
Correct answer: A. Resuscitation followed by enterolithotomy through an antimesenteric incision proximal to the stone
Explanation
The radiograph shows Rigler's triad (small bowel obstruction, pneumobilia, ectopic gallstone), diagnostic of gallstone ileus from a cholecysto-enteric fistula. Standard management is fluid resuscitation and enterolithotomy alone at the site of impaction, usually the terminal ileum. Definitive fistula closure and cholecystectomy are avoided in the same sitting unless the gallbladder is gangrenous or the patient is fit, because they add morbidity in elderly patients.
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.