Abdominal Pain and Hypotension in a 70-Year-Old Woman.

A 70-year-old woman with hypertension, atrial fibrillation, congestive heart failure, and gallstones had 3 days of nausea, vomiting, and abdominal pain. Abdominal computed tomography showed a thickened gallbladder wall with intraluminal air adherent to the duodenum and a gallstone in the middle ileum with proximal bowel distension. What is the diagnosis and what would you do next?

Reasoned diagnostic approach to a case of small bowel obstruction.

The case of a 73-year-old male patient come to the Emergency Department for epigastric pain, vomiting and blocked bowel movement is presented. Plain abdominal X-ray performed on emergency showed marked small bowel distention, and air-fluid levels suggestive of intestinal obstruction. CT was indicated to establish its precise site and cause. The presence of a gallstone was evidenced: gallstone ileus was diagnosed. Interestingly enough, at surgery the gallstone was not found; most likely it was expelled spontaneuously during the time elapsed between CT and surgery. Based on imaging findings and a review of the literature it was concluded that the study patient had a rare association of intestinal volvulus and gallstone ileus.