CASE 13124 Published on 20.11.2015

Gallstone Ileus with prospective diagnosis of Crohn\'s


Abdominal imaging

Case Type

Clinical Cases


Talath Biyabani, Muhammad Naeem, Haniya Kazi, Amjad Mohammed, Naeem Jagirdar

Bradford Teaching Hospitals NHS Trust, Duckworth Lane, Bradford

62 years, female

Area of Interest Abdomen ; Imaging Technique CT
Clinical History
A 64 year old female patient presented with abdominal pain, vomiting and diarrhoea, which had been worsening over a week's time. She had a past medical history of treated hypertension, hypercholesterolemia and gastro-oesophageal reflux - a previous endoscopy had revealed a duodenal ulcer.
Imaging Findings
Supine abdominal radiographs demonstrated dilated small bowel loops (Fig 1), in keeping with high grade mechanical small bowel obstruction and a calcific -(arrows) structure in the pelvis (Fig 2).
Axial CT image demonstrated a cholecystoduodenal fistula with pneumobilia (Fig 3) and a gallstone lodged in the terminal ileum (Fig 4) with abnormal thickening and enhancement of the terminal ileum causing high grade mechanical small bowel obstruction coronal image (Fig 5).
The major vascular pedicles, the coealic, superior mesenteric artery were all patent with no mural gas or other features to suggest small bowel ischemia.
Gallstone ileus is a very rare cause of bowel obstruction, even in patients with Crohn’s disease [1-5]. It is well known that patients with Crohn’s disease are at increased risk of developing gallstone disease [6], especially when the terminal ileum is involved. In these cases a biliary-enteric fistula is usually seen and instead of the calculus lodging at the ileocecal valve, it does so in the segment of small intestine that is stenosed due to Crohn’s. Cases of small bowel obstruction caused by foreign bodies impacting at stenosed bowel segments in patients with Crohn’s have been described. They usually occur in elderly individuals who have had Crohn’s for a long time [7-9] and in some cases, the diagnosis of Crohn’s is indeed made at a surgical laparotomy [10].
Our patient presented with symptoms of bowel obstruction with no established diagnosis of Crohn’s. The plain abdominal radiograph performed at the time of the admission demonstrated features of small bowel obstruction with dilated small bowel loops centrally in the abdomen. There was no free gas and a CT was requested to identify a cause for the small bowel obstruction, as the gallstone was only noticed in retrospect after the CT had been performed. The CT demonstrates a cholecysto-duodenal fistula with pneumobilia and a gallstone lodged in the terminal ileum with abnormal thickening and perienteric hypervascularity with a Coomb’s sign type picture in the terminal ileum. The small bowel loops proximally were secondarily dilated. There were some reactive nodes in the small bowel mesentery. The patient was operated and had an obstructive gallstone lodged in the terminal ileum, which was removed. The additional finding of the thickened terminal ileum was also confirmed at laparotomy and histologically this was reported as Crohn’s.

Teaching points:
1. Gallstones are common in patients with IBD and can present with gallstone ileus.
2. Interrogate the plain abdominal radiograph carefully with particular emphasis to the right upper quadrant looking for pneumobilia and the right iliac fossa region for possible gallstones lodged in the terminal ileum with dilated small bowel loops proximally.
3. Interrogate the small bowel carefully around the site of obstruction - as in this case, where the immediate ileum proximal to the site of obstruction is abnormal, which was biopsied and led to final diagnosis of underlying Crohn's.
Differential Diagnosis List
Gallstone ileus with high grade small bowel obstruction and a prospective diagnosis of Crohn's.
Foreign body
Final Diagnosis
Gallstone ileus with high grade small bowel obstruction and a prospective diagnosis of Crohn's.
Case information
DOI: 10.1594/EURORAD/CASE.13124
ISSN: 1563-4086