Gallstone ileus masquerading as an obstructed femoral hernia

Gallstone ileus affects primarily elderly women. In many instances, no history of previous biliary disease is discernible. Although it has been known since the 17th century, gallstone ileus continues to present in such an intriguing way that, more often than not, the diagnosis is made intraoperatively. A 68-year-old woman, presented with abdominal pain and vomiting. She had a slightly distended and mildly tender abdomen, and the bowel sounds were normal. There was an irreducible, slightly tender right femoral hernia. Plain X-rays of the abdomen were normal and an ultrasound showed a contracted fibrotic gall bladder with small stones. Laparoscopy failed to detect an obstructing gallstone, which was discovered in a second laparotomy. Cholecystectomy and fistula closure were carried out in the same sitting. A retrospective review of a preoperative Gastrografin study showed clear radiological evidence of the condition. Gallstone ileus tends to be forgotten as a cause of bowel obstruction or abdominal pain in elderly women. With this in mind, careful interpretation of a Gastrografin study might provide the diagnosis preoperatively. In relatively fit patients, cholecystectomy and fistula closure could be safely added to the emergency enterolithotomy.