Leave no stone unturned in case of groans.

To cite: Hoekstra RJ, Smakman N, Sanders FBM, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2013201991 DESCRIPTION An 84-year-old woman presented to our emergency room with abdominal symptoms since a couple of weeks. She reported vomiting and absence of defaecation for 3 days. Her medical history revealed myocardial infarction and an appendectomy. Physical examination was unremarkable, except for a distended abdomen and hypoactive bowel sounds. An abdominal CT scan revealed air in the intrahepatic gall ducts and ductus choledochus (pneumobilia), dilated bowels, an occluding gallstone and some smaller gallstones in the proximal ileum (figure 1). She underwent an emergency laparotomy with successful enterolithotomy (figure 2). A gallstone ileus is caused by a gallstone that mechanically occludes the intestines. It is a rare complication of cholelithiasis and occurs in less than 0.5% of patients, but accounts for 25% of the small bowel obstructions in patients over 65 years of age. After inflammation of the gall bladder and adherence to a close bowel, mostly the duodenum (60%), a biliary enteric fistula can be formed. The passage of large gallstones can result in obstruction, most frequently (50–70%) in the ileum, since it is the narrowest segment of the intestine. Pneumobilia is seen in 30–60%. Since age and female sex are major risk factors for the development of gallstones, gallstone ileus is mostly seen in the elderly with a female preponderance. The spontaneous passage of a stone is rare. Enterolithotomy is the cornerstone of treatment. Concomitant cholecystectomy, fistula division and common bile duct exploration can be considered, but high-risk patients can be managed by stone extraction only, since the risk for recurrent gallstone ileus or cholecystitis is low.