Abdominal pain and vomiting in an elderly diabetic woman

Gall stone ileus is a mechanical bowel obstruction caused by passage of gall stones from the biliary system through a biliaryenteric fistula with impaction within lumen of the bowel. It is an uncommon complication of biliary stone disease, accounting for only 2% of all cases of intestinal obstruction. Gall stone ileus is, however, more common in the elderly and accounts for approximately 25% of all cases of intestinal obstruction in patients over 65 years of age. The gall stone that causes ileus is usually more than 2.5 cm in diameter. Multiple stones are present in 3%–15% of cases. 2 Gall stones usually enter the intestinal lumen through a cholecystoenteric fistula, and 68% of these are between the gall bladder and the duodenum. A history of prior biliary tract disease is present in almost 50%–60% of patients with gall stone ileus. The most frequent site of stone impaction is the ileum (.60% of cases), as it is the narrowest part of the bowel. Other sites of obstruction are the jejunum (16%), stomach (14%), colon (4%), and duodenum (3%). Gastric outlet obstruction, or Bouveret’s syndrome, occurs when the gall stone lodges in the duodenal bulb (1%). Clinical features Usually abdominal pain is a prominent symptom, and associated illnesses such as diabetes and cardiovascular disease are common. It causes signs of small bowel obstruction like nausea, vomiting, abdominal distension, and absence of bowel sounds in cases of complete obstruction. Signs of intestinal obstruction are seen mostly if the gall stone impacts at the ileocaecal junction. However, the characteristic features of intestinal obstruction are found in only 50% to 70% of patients. 3 This may be because as the gall stone ‘‘tumbles’’ through the gastrointestinal tract, it impacts and disimpacts, producing intermittent mechanical obstruction.