To leave no stone unturned: cholelithiasis and subsequent gallstone ileus.

To cite: Yong E, Chiu TF, Kamel H, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2016215348 DESCRIPTION A 68-year-old man was admitted after a sudden collapse and a 5-day history of severe vomiting. On admission, he was hypotensive with a blood pressure of 70/60 mm Hg and had to be fluid resuscitated with 3 L of intravenous fluids via a femoral venous catheter. A nasogastric tube was inserted and 1600 mLs of brown vomitus aspirated. Venous blood gas showed a lactate of 5 mmol/L. The patient was in acute renal failure with urea of 30 mmol/L and creatinine of 224 μmol/L. On surgical review, he was not thought to be clinically obstructed and an abdominal radiograph showed some sentinel loops but otherwise did not reveal any obvious bowel dilation (figure 1). The patient had had a CT scan a month earlier when he had been staged for newly diagnosed prostate cancer; the scan had visualised a calcified circular opacity with a laminated appearance consistent with a gallstone in the gallbladder (figure 2). A repeat scan now revealed dilated fluid-filled jejunal loops, one of which contained the same opacity consistent with migration of the gallstone (figure 3). The patient was sent to the operating theatre for a laparotomy, which revealed obstruction in the jejunum secondary to a calculus with proximal bowel dilation and distally collapsed bowel. There were no other calculi noted on careful inspection of the bowel. In addition, neither jejunal nor ileal diverticuli nor associated stercoliths were noted, thus excluding the similarly rare differential of bowel obstruction secondary to stercolith expelled from small bowel diverticula. As the bowel appeared viable, it was deemed that there was no need for bowel resection and re-anastomosis. The patient underwent an open enterolithomy (figure 4). A gallstone measuring 4×3 cm was delivered via a longitudinal incision performed on the antimesenteric border of the small bowel, which was then closed in two layers in a transverse fashion to reduce risk of subsequent stricture formation. His postoperative course was uneventful (figure 5), and plans were made for an elective cholecystectomy at a later date. Gallstone ileus is an uncommon surgical emergency accounting for 0.1–5% of all mechanical