ZSFG AM Report Pearls 2/9/2018: It’s A Hard Rock Life For Us: Gallstone Ileus

Thank you to Elise, one of ZSFG’s rockstar BRIDGES MS3s, who presented a fascinating case of a patient who presented with nausea and abdominal pain who was found to have a gallstone ileus likely from a large gallstone that erode through the bowel wall and became lodged in the ileocecal valve.


DDx Air in the Gallbladder

  1. Post-procedure (i.e. ERCP)
  2. Gas-forming bacteria
  3. Biliary-enteric fistula


Gallstone Ileus:

  • Caused by impaction of a gallstone in the ileum after being passed through a biliary-enteric fistula
  • Complicates 2-3% of all cases of cholelithiasis associated with episodes of cholecystitsis
    • 60% are cholecystoduodenal fistulas
  • Episodic subacute obstruction (resulting from “tumbling” of the stone through the bowel)
  • Fevers, abdominal distension, increased bowel sounds, jaundice in <15% of cases, only 20% of pts have signs consistent with cholecystitis
  • Leukocytosis
  • Elevated transaminases
  • CT is the most common, but plaine filsm and US can be used
  • Surgical removal of the obstructing stone



  • Ming-Bing Wu, Wen-Feng Zhang, Ying-Lin Zhang, Di Mu, Jian-Ping Gong. (2015) Choledochoduodenal fistula in Mainland China: a review of epidemiology, etiology, diagnosis and management. Annals of Surgical Treatment and Research 89, 240.
  • (1997) Gallstone Ileus. New England Journal of Medicine 336:12, 879-880.


  • DDx of Air in Gallbladder: https://www.evernote.com/shard/s509/sh/98d6541a-0207-408e-b262-0d81a5a54573/681c5f291c683c81fc32e6dd0cf8013b
  • Gallstone Ileus: https://www.evernote.com/shard/s509/sh/37b86793-69eb-4184-aea8-86903ebe4d0f/91fadbe81f9c280ca17a12e38373b441

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