Gallstone ileus diagnosed by computed tomography

A 79-year-old man presented with diarrhoea and vomiting but with no abdominal peritoneal signs. He had a raised C-reactive protein level, but other blood test results (including amylase and liver function) and an abdominal radiograph were within normal limits. After conservative treatment failed, the patient underwent colonoscopy, which revealed cobblestone nodularity with ulceration in the terminal ileum, consistent with Crohn’s disease. There was no evidence of large bowel obstruction. A subsequent computed tomography scan revealed concentric circles in the terminal ileum consistent with a gallstone (Box). A diagnosis of gallstone ileus was made and the gallstone was removed with laparoscopic assistance. A fistula between the gallbladder and the duodenum, observed at operation, was left alone. The patient made an uneventful recovery.