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BACKGROUND Gallstone ileus is an uncommon cause of intestinal obstruction. Rigler's classic triad for a gallstone ileus includes the following: small bowel obstruction, air in the biliary tract, and an obstructing gallstone. This triad, however, is not always observed. We present an unusual case of a gallstone present in the small bowel for several years prior to presenting with an acute obstruction. CASE REPORT A 71-year-old man presented with 3 days of lower abdominal pain, constipation, and abdominal distension, with his last reported bowel movement 3 days prior. The patient's vitals were stable, with a white blood cell count of 11.47×10⁹/L and no lactic acidosis. Abdominal exam was significant for bilateral lower-quadrant tenderness and mild distension. Findings on abdominal computed tomography revealed a large foreign body in the distal small bowel, with evidence of proximal small bowel obstruction. Review of imaging from 4 years prior incidentally revealed the foreign body more proximally in the jejunum. Laparoscopy and enterotomy were performed with removal of a 4×4 cm gallstone encased in fecal material. The patient recovered well from surgery and had no complications. CONCLUSIONS A 71-year-old man presented with lower abdominal pain and distension. Work-up revealed a small bowel obstruction secondary to a presumed foreign body, later found to be a gallstone. We present a highly unusual presentation of a gallstone ileus, with radiographic evidence of an enteric gallstone present 4 years prior, with no evidence of pneumobilia or biliary-enteric fistula in current or previous computed tomography scans.

The "tumbling gallstone sign" is a diagnostic imaging finding described on radiologic examinations of the abdomen, in patients with cholelithiasis associated with intermittent episodes of gallstone obstructive ileus.  Best seen on serial radiographs or CT studies of the abdomen, this sign indicates a sudden change in position of the gallstone(s) within the intestinal lumen from the upper segments of the bowel to the lower segments of the bowel, causing transient mechanical bowel obstruction.  The tumbling gallstone sign has been likened to that of the classic childrens' tumbling tower balancing game.  On repeat CT scans, the dislodged gallstone(s) may be seen proceeding distally and impact in the ileum at a level lower than that seen on the previous CT scans, analogous to the tumbling gallstone sign.

Gallstone ileus is a rare complication of cholelithiasis, characterized by mechanical bowel obstruction due to a biliary calculus originating from a bilioenteric fistula. The Rigler triad, consisting of aerobilia, ectopic gallstone, and intestinal obstruction, is rarely observed in its complete form. We present the case of a 92-year-old male with a history of acute lithiasic cholecystitis who presented to the Emergency department with acute epigastric pain. Initial evaluation revealed gallbladder dilatation, gallstones, and gallbladder wall thickening suggestive of acute cholecystitis. During hospitalization, the patient experienced an episode of hematemesis, leading to the diagnosis of a cholecystoduodenal fistula and a large blood clot in the duodenal bulb. Further imaging showed an ectopic gallstone causing small bowel obstruction. The patient underwent urgent surgery for stone extraction, followed by endoscopic intervention for the bleeding vessel identified at a subsequent gastroscopy. Unfortunately, the patient had a poor postoperative course and passed away seven days later. This case report highlights the exceptional occurrence of both the Rigler triad and upper gastrointestinal bleeding in a patient with gallstone ileus. Surgical intervention is crucial for the initial resolution of intestinal obstruction, followed by cholecystectomy and repair of the bilioenteric fistula. Awareness of these rare presentations is important for timely diagnosis and appropriate management of this uncommon complication of cholelithiasis.

This report describes a case of a patient with active multiple myeloma who was started on bortezomib, cyclophosphamide and dexamethasone and subsequently presented to the emergency department with acute intestinal obstruction one week later. The patient underwent exploratory laparotomy, but no mechanical cause of the obstruction was found. The patient later developed sepsis and eventually died. The possible cause of the intestinal obstruction was attributed to bortezomib, and the paper discusses the potential mechanism of this side effect and its management based on available literature., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

In this article, we present case reports of two patients admitted to the University Hospital in Pilsen for acute abdomen due to a disorder of the passage through the gastrointestinal tract (GIT). Both were indicated for surgery. The patients were diagnosed intraoperatively with rarely occurring cecal volvulus (CV). The findings required an ileocecal resection; nevertheless, both patients fully recovered despite the need the resection.

Objective: Small bowel obstruction (SBO) is a common and important surgical emergency. Our aim in this study is to describe the clinical, laboratory, and computed tomography (CT) findings to facilitate the objective identification of SBO patients in need of operative treatment in this patient population., Methods: This retrospective study included 340 patients hospitalized due to a preliminary diagnosis of ileus. Retrieved data of patients included age, gender, comorbidities, previous hospitalization due to ileus, surgical history, physical examination findings, complete blood count and biochemistry test results, and CT findings at admission., Results: The study included 180 (52.9%) male and 160 (47.1%) female patients. Treatment was conservative in 216 patients and surgery in 124 patients. Of the patients included in the study, 36.4% needed surgery. Of the female patients, 38.90% received conservative treatment and 61.30% underwent surgery. Adhesions were the most common cause of obstruction in operated patients (43.50%)., Conclusion: We have found that female gender, vomiting, guarding, rebound, C-reactive protein levels above 75 mg/L, increased bowel diameter, and a transition zone on CT images indicate a strong need for surgery, but a history of previous hospitalization for ileus may show that surgery may not be the best option., (Copyright: © 2024 Permanyer.)

Gallstone ileus occurs when the small or large intestine is obstructed by a gallstone and is a rare occurrence in a post-cholecystectomy patient. Non-specific clinical symptoms and inconsistent imaging results often lead to a delay in diagnosis. Complex anatomy, such as a Roux-en-Y biliary-enteric anastomosis, can increase the risk of stone formation and further confound a potential case of gallstone ileus. Here, we present a rare case of gallstone ileus at the anastomosis site of a Roux-en-Y hepaticojejunostomy done 30 years prior for a common bile duct injury during a cholecystectomy. The possibility of negative CT findings, pattern of presentation on imaging as intussusception, and potential pathomechanism of gallstone formation in post-cholecystectomy patients are discussed. Through this case and review of similar cases, we emphasise the need for further study of post-cholecystectomy gallstone ileus and the importance of clinical suspicion during diagnosis., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Meckel's diverticula result from incomplete obliteration and regression of the omphaloenteric duct and are the most common congenital intestinal malformations. Many Meckel's diverticula remain asymptomatic and are discovered as incidental findings. They present a diagnostic challenge., Methods: We report the case of a 35-year-old man who presented with an acute abdomen and ileus. Computed tomography of the abdomen showed a mechanical small bowel ileus. There was a calibre jump in the terminal ileum with a round endoluminal definable hyperdense structure of almost 2 cm in diameter., Results: An exploratory laparoscopy was performed revealing an inflamed Meckel's diverticulum with impacted enterolith as the cause of the intestinal obstruction., Conclusion: In symptomatic Meckel's diverticula, haemorrhage and obstruction are the most common complications. The development of ileus due to a Meckel's diverticulum with an enterolith is considered extremely rare but should be taken into account.

Gallstone ileus is an uncommon but well-described occurrence in general surgery. However, discrepancy regarding optimal surgical management with 1 or 2 stage operation is still debated. This case report presents a 73-year-old woman who presented to the emergency department (ED) with a small bowel obstruction due to a gallstone lodged in a portion of the proximal ileum. The patient was also noted to have persistent cholelithiasis and cholecystoduodenal fistula. A single-stage surgery involving enterolithotomy, cholecystectomy, fistula repair, and cholangioscopy was performed. The patient progressed well and was discharged home without recurrent symptoms. Therefore, in a hemodynamically stable patient with persistent cholelithiasis or choledocholithiasis, it is reasonable to perform a definitive single-stage operation., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Gallstone ileus is a rare complication of complicated gallbladder disease. Typically the result of a cholecystocholeduodenal fistula, a gallstone enters the small bowel and impacts in the ileum causing an obstruction. In this case study, a 74-year-old male presented to the emergency department with nausea, vomiting, and constipation for 2 weeks. CT revealed pneumobilia and a 3.1 cm calcified mass in the terminal ileum. The patient was successfully treated with a robotic-assisted enterotomy alone without complications.

Objective: We aimed to examine the factors contributing to radiation exposure exceeding the DRL of the transnasal ileus tube placement in this post hoc analysis from the cohort of the REX-GI study., Methods: Patients with transnasal ileus tubes were enrolled in the rex-gi study from may 2019 to december 2020. We investigated the endoscope insertion time (min), procedure time (min), tube insertion length (cm), fluoroscopy time (FT: min), air kerma at the patient entrance reference point (K a.r : mGy), and air kerma-area product (P KA : Gycm 2 ). The third quartile value of the P KA value was calculated as the diagnostic reference level (DRL) value. We explored the factors associated with radiation exposure exceeding the DRL., Results: In the REX-GI study, 496 patients who underwent transnasal ileus tube placement were enrolled. The median age of the patients was 71 years. The median endoscopy insertion time, procedure time, and tube insertion length were 6 min, 20 min, and 170 cm, respectively. The third quartile/median FT, K a.r , and P KA were 18/11.9 min, 99.2/54.4 mGy, and 46.9/28 Gycm 2 , respectively. The third quartile value of P KA (47 Gycm 2 ) was set as the DRL value. There were differences in distribution by the hospital. Compared with procedures under the DRL, the FT (19 vs 10 min), procedure time (25 vs 18 min), and tube insertion length (185 vs 165 cm) were significantly longer for procedures above the DRL., Conclusion: We report the DRL for transnasal ileus tube placement in Japan. A longer procedure time and tube insertion length may be associated with DRL exceedance., Advances in Knowledge: Transnasal ileus tube placement under fluoroscopy guidance is a standard clinical procedure for bowel obstruction. However, the appropriate radiation dose level has not yet been established.We report the (DRL) for transnasal ileus tube placement in Japan. A longer procedure time and tube insertion length may be associated with DRL exceedance.

Gallstones are common, but rarely cause ileus. This case report illustrates the clinical course of a patient who developed gallstone ileus without any previously identified gallstone symptoms.

Gallstone ileus is a rare complication of cholecystoduodenal fistula. Gastric ischemia due to intestinal obstruction is an extremely rare event that, if not diagnosed in time, can have a fatal outcome. We present the case of a patient with intestinal occlusion due to a gallstone obstructing the middle jejunum in which gastric ischemia was diagnosed intraoperatively due to the distension caused by the intestinal obstruction.

Recurrent gallstone ileus has a recurrence of 2-8.2% with a mortality of 12-20%, secondary to an enteric or cholecystic gallstone. A male patient with a diagnosis of intestinal occlusion secondary to biliary ileus and cholecystoduodenal fistula, performing enterotomy and closure in two planes with drainage placement. Two months after presenting the clinical of intestinal occlusion, medical management began and an abdominal tomography was performed, finding an image suggestive of recurrent gallstone ileus, treated with laparotomy., (Copyright: © 2023 Permanyer.)

Ileus is one of the most severe diagnoses of the group of acute abdomen events. Some patients with certain forms of bowel obstruction respond well to conservative therapy. However, the diagnosis of strangulation ileus can be delayed in some situations, resulting in high morbidity and mortality in such cases. Our paper presents the case of an 81-year-old female patient who developed an ileus shortly after ureteral stent placement due to obstructive hydroureteronephrosis. The strangulation of the small intestine was caused by an atypical position of the right ureter in the abdominal cavity.

Gallstone ileus is a rare complication of gallstones and is a comparatively unique cause of intestinal obstruction. It involves the development of a cholecysto-enteric fistula through which a gallstone can pass into the gastrointestinal tract. Spontaneous resolution of intestinal obstruction in gallstone ileus is extremely rare. We report a 71-year-old patient who presented with right hypochondrial pain for four months. She had a three-day history of absolute constipation and abdominal distention two months before presentation that resolved spontaneously. Computed tomography revealed pneumobilia. Laparoscopic exploration showed a cholecysto-duodenal fistula that was divided, the opening in the first part duodenum was closed and cholecystectomy was completed successfully. The presence of pneumobilia in a patient with gallstones should raise the suspicion of bilio-enteric fistula. The obstruction component of gallstone ileus can resolve spontaneously in rare occasions. Single stage laparoscopic management of cholecysto-duodenal fistula is safe and feasible in the presence of an experienced laparoscopic surgeon.

We report the use of indocyanine green (ICG) fluorescence for intraoperative diagnosis in two cases of strangulated ileus. We successfully preserved the bowel and avoided postoperative complications by detecting adequate perfusion and no necrosis in the intestine's strangulated regions. In the first case, enhanced computed tomography (CT) revealed a closed loop intestine, which showed poor contrast, and we performed laparotomy with ICG fluorescence. In the second case, the CT scan revealed bowel obstruction without ascites. We conservatively treated the patient with the insertion of a long tube. The patient's condition did not improve, and we performed laparotomy using ICG fluorescence. In both of these cases, the visual observation during laparotomy showed that the ileum had dark-red discoloration. We demonstrated perfusion and preserved the ileum by injecting 2.5 mg of ICG intravenously; fluorescence was observed in the dark-red ileum using the PINPOINT system (Novadaq, Kalamazoo, MI, US). Both patients recovered successfully after the surgery with no adverse events. Our data suggest that ICG fluorescence imaging can be one of the decision-making modalities in patients with strangulated ileus., (© 2022. Japanese Society of Gastroenterology.)

Introduction: Delayed bowel function (DBF) and postoperative ileus (POI) are common gastrointestinal complications after surgery. There is no reliable imaging study to help diagnose these complications, forcing clinicians to rely solely on patient history and physical exam. Gastric point of care ultrasound (POCUS) is a simple bedside imaging technique to evaluate gastric contents but has not been evaluated in postoperative patients., Methods: Twenty colorectal patients were enrolled in this pilot study. Patients were categorized as either full or empty stomach based upon their postoperative day one gastric POCUS exams and previously published definitions. The primary outcome was GI-3 recovery, a dual end point defined as tolerance of solid food and either flatus or bowel movement. Secondary outcomes were length of stay, emesis, time to first flatus, time to first bowel movement, nasogastric tube placement, aspiration events, and mortality., Results: Nine of 20 patients had a full stomach postoperatively. Patients with full stomachs were younger and received greater perioperative opioid doses (74.0 ± 28.2 v 42.6 ± 32.9 morphine equivalents, P = 0.0363) compared to empty stomach patients. GI-3 recovery occurred significantly later for patients with postoperative day 1 full stomachs (2.1 ± 0.4 versus 1 ± 0 days, P = 0.00091)., Conclusions: Based upon this pilot study, gastric POCUS may hold promise as a noninvasive and simple bedside modality to potentially help identify colorectal patients at risk for postoperative DBF and POI and should be evaluated in a larger study., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: The horizontal beam (HB) view has been used in the identification of pneumothorax, pleural effusion, and pneumoperitoneum in small animals. Based on the literature, there were no published data evaluating the utility of HB radiography in vomiting dogs to differentiate between patients with or without mechanical gastrointestinal ileus., Aim: The purpose of this prospective pilot study was to determine the utility of HB radiograph as an additional view in vomiting dogs to differentiate patients with or without mechanical gastrointestinal ileus; and describe if there are any radiographic image characteristics associated with the HB view for patients with mechanical gastrointestinal ileus., Methods: A prospective study was carried out on dogs presented with acute vomiting. For all dogs, four radiographic views [ventrodorsal (VD), right lateral, left lateral, and left-to-right lateral HB in sternal recumbency] of the abdomen and abdominal ultrasound were obtained. If a mechanical ileus was detected ultrasonographically, an exploratory laparotomy or endoscopy was performed, otherwise medical treatment was elected., Results: A total of 22 patients were recruited, 11 diagnosed with mechanical ileus and 11 without mechanical ileus. Three blinded reviewers independently assessed the radiographs in three sets: vertical beam (VB) views, HB view alone, and a combination of both views. No statistical difference was found in the differentiation between patients with or without mechanical gastrointestinal ileus between HB views alone or added to VB views., Conclusion: This study suggests that the HB view in sternal recumbency may be an alternative for patients who are not stable enough to be positioned in lateral or VD recumbency., Competing Interests: The authors declare that they have no conflict of interest. Fig. 3.Example of crowding organs at the ventral aspect of the abdomen in a left-to-right lateral HB view. Evaluation of the ventral abdomen is challenging due to presence of fluid/soft tissue-filled intestines and concurrent peritoneal effusion.

Background: Gallstone ileus (GI) is a rare entity which is seen in 0.5% of patients with cholelithiasis. In this study, we aimed to share our clinical approach to GI, to present our long-term results and to draw clinicians' attention to this rare entity., Materials and Methods: This study included 11 patients with GI whose medical records were evaluated retrospectively., Results: Majority of the 11 patients were female (63.7%, n:7) and the mean age was 71.9 ± 14.10 (range: 50-91). Most common presenting complaints were vomiting ( n : 9) and abdominal pain ( n : 9). The mean interval from the onset of symptoms to the hospital admission was 3.8 ± 0.75 (range 3-5) days. Rigler triad in abdominal computed tomography (CT) was detected in all cases. Enterolithotomy, one-step procedure and conservative treatment were performed in five (45.4%), four (36.3%) and two (18.1%) patients, respectively. Enterolithotomy group was found to have higher risk according to American Society of Anesthesiologists (ASA) classification, shorter operation time and less intraoperative blood loss., Conclusion: Although enterolithotomy is the first choice for patients with GI, one-step procedure should be kept in mind as a more advantageous technique in low-risk patients.

Gallstone ileus is an uncommon complication of cholelithiasis and occurs when a gallstone migrates through a cholecystoenteric fistula and impacts within the gastrointestinal tract. Surgical intervention remains the treatment of choice, which consists of a full-thickness incision of the visceral wall and removal of the impacted gallstone. In this paper we present the treatment approach of 6 cases of gallstone ileus in octogenarians. In our cohort, intestinal obstruction was resolved through an enterotomy or gastrotomy and lithotomy/stone extraction in every patient. No cholecystectomies were undertaken. Despite the fact that gallstone ileus is diagnosed in small percent of patients suffering from gallstone disease, it accounts for a large proportion of intestine obstruction in patients older than 65 years old. Since accurate diagnosis and timely intervention are vital, providers should be familiar with the diagnostic approach and the treatment of this clinical entity.

Case Summary: A 22-year-old woman with medically refractory ulcerative pancolitis underwent laparoscopic total proctocolectomy with IPAA and diverting ileostomy. She was discharged on postoperative day 4 feeling well. Because of the lack of risk factors for venous thromboembolism (including no family history or use of oral contraceptives), she was not discharged with prophylactic low-molecular-weight heparin, but she received low-molecular-weight heparin while in the hospital. The following day, she developed abdominal pain, nausea/vomiting, and decreased ostomy output. An abdominopelvic CT scan demonstrated a small amount of intraperitoneal free air felt to be postoperative in nature, small-bowel dilation consistent with ileus, and extensive portal and superior mesenteric vein thrombosis. She was started on low-molecular-weight heparin that resulted in rapid improvement. A subsequent repeat CT scan a few days later showed decreased clot burden., (Copyright © The ASCRS 2021.)

Competing Interests: Competing interests: None declared.

Midgut malrotation and internal herniation due to Ladd's band in adults is sparsely described. Due to the low incidence and the uncharacteristic symptoms, the diagnosis and treatment is often delayed causing increased morbidity. In this case report, a 68-year-old man was hospitalised with severe abdominal pain. A computed tomography showed abnormal placement of the small bowel loops and torsion of the small bowel mesentery. He underwent a laparoscopic procedure which revealed internal herniation due to a Ladd's band. He recovered uneventfully, and an elective Ladd's procedure was scheduled.

We describe the case of a 73-year-old woman with a high body mass index and a virgin abdomen who presented with a 5-day history of abdominal pain, emesis and confusion on admission. Inflammatory markers and renal function were significantly deranged. CT of the abdomen and pelvis demonstrated a clear transition point and faecalisation of the small bowel proximal to the obstruction. It was suggested that the patient may have ingested a foreign object. A collateral history was obtained, making this less likely and confirmed an acute cognitive impairment. She was optimised following multidisciplinary discussion preoperatively. Thereafter, the patient underwent a laparotomy, where a hard, mobile mass was identified in the jejunum. This was diagnosed as an enterolith of dimensions 62×38×32 mm secondary to a duodenal diverticulum. She improved postoperatively with complete resolution of her confusion and renal function. She was discharged on day 14 of admission., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Small bowel diverticulosis is rare. False diverticula form in the jejunum, and less commonly, the ileum. As with their large bowel counterparts, these diverticula provide a pocket for stasis of bowel content, leading to the formation of enteroliths. This case report highlights two complications from jejunal diverticulosis: jejunal diverticulitis and a small bowel obstruction as a result of enterolithiasis; the latter being a rare entity which should be a differential diagnosis for any individual presenting with gastrointestinal obstructive symptoms and radiological evidence of small bowel diverticulosis., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)