An unusual cause of abdominal pain in a middle-aged man.

To cite: Abukar AA, Leung P, Vulliamy P, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/ bcr-2015-211986 DESCRIPTION A 53-year-old man with a history of hypercholesterolaemia and symptomatic cholelithiasis presented with a 1-day history of bilious vomiting, intermittent abdominal pain, anorexia and absolute constipation. Physical examination revealed a mildly distended, tense abdomen that was tender in the lower quadrants. Percussion note was tympanic and bowel sounds were absent on auscultation. An urgent CTof the abdomen and pelvis was requested (figure 1). CT showed evidence of mild fatty infiltration of the liver and emphysematous cholecystitis without cholelithiasis. There was also evidence of a moderate amount of pneumobilia, mildly dilated small bowel loops and a well-defined radiodense material noted in the ileum. The patient was resuscitated and underwent laparotomy and enterolithotomy, with the consequent retrieval of a large 4 cm gallstone (figure 2). The postoperative course was uneventful and the patient was discharged following 2 weeks of hospital stay. The features described are characteristic of gallstone ileus, namely, Rigler’s triad, which classically includes mechanical bowel obstruction, ectopic gallstone within the bowel lumen and pneumobilia. Plain abdominal radiographs usually display nonspecific findings as only a few (10%) gallstones are sufficiently calcified to be seen radiographically. Abdominal ultrasound scan may confirm presence of gallstones and a fistula. However, abdominal CT scan is the gold standard in diagnosing gallstone ileus due to its superior resolution. Lanssandro and colleagues found that Rigler’s triad was present in 11.11% of patients on abdominal ultrasound scan, 14.81% on plain abdominal radiograph and 77.78% on abdominal CT scan. Use of CT scan may result in a faster diagnosis and also aids decision-making in the surgical management. 2 Learning points