A 72-year-old woman presents with 3 days of abdominal distension, bilious vomiting, and absolute constipation. She has a history of recurrent biliary colic. Abdominal radiograph shows small bowel air-fluid levels, gas in the biliary tree, and a calcified opacity in the right iliac fossa. After resuscitation, the most appropriate surgical procedure is:

• A Cholecystectomy with takedown of the cholecystoduodenal fistula in the same sitting
• B ERCP with balloon extraction of the ectopic stone
• C Right hemicolectomy with primary anastomosis
• D Enterolithotomy through an incision proximal to the impaction ✓

Explanation

The findings are Rigler's triad of gallstone ileus: small bowel obstruction, pneumobilia, and an ectopic calcified gallstone. The stone enters the gut via a cholecystoduodenal fistula and impacts most often at the narrow terminal ileum. The emergency operation is simple enterolithotomy; definitive fistula closure and cholecystectomy are deferred or staged because dissection in inflamed tissue raises morbidity in these elderly patients. Right hemicolectomy is reserved when the stone cannot be milked back and perforation is suspected.

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.