gallstone ileus is an uncommon complication of gall stones associated with potentially serious morbidity and mortality .
we reported a 60-year - old male case who presented with renal failure and pain in right hypochondriac region .
he also had a history of brain infarcts along with diabetes which is an additional factor for mortality . on computed tomography of the abdomen
, he was diagnosed to have cholecystocholedochal fistula including air in the gall bladder and obstruction in the distal part of the ileum .
as in our case , diagnosis was challengeable because of renal failure , diabetes , septicaemia and intestinal obstruction ( peritonitis ) .
we did surgery on the basis of peritonitis which remains the only choice in such cases .
 gallstone ileus  to refer to mechanical intestinal obstruction due to impaction of gallstones within the intestine .
gallstone ileus is a rare complication of gallstones that occurs in 1 - 4% of all cases of bowel obstruction and in up to 25% of cases of non - strangulated small - bowel obstruction in patients over 65 years of age .
the condition should be suspected in all patients presenting with features of small - bowel obstruction in absence of a surgical scar and external hernia , especially in elderly females .
the diagnosis can always be confirmed by plain x - ray , ultrasound and computed tomography ( ct ) scan .
a 60-year - old male presented with vomiting and abdominal pain , which had lasted for two days , in maharishi markandeshwer institute of medical sciences and research , mullana , distt - ambala , india in march , 2011 .
patient had been previously treated in a private hospital for intestinal obstruction using ryle 's tube aspiration , intravenous fluids , and antibiotics .
he had also been kept orally nil for about 1 week , but there was no relief .
there was also a history of old brain infarcts and he was a known diabetic on regular treatment .
abdominal examination revealed only tenderness on the right side while the rest of the abdomen was soft and bowel sounds were present . on blood tests ,
elevated total leukocyte counts ( 15,500 /cu mm ) , blood urea ( 96 mg / dl ) , and creatinine ( 2.6 mg / dl ) were observed .
on contrast enhanced computed tomography ( cect ) , there was a stone / stricture / obstruction in distal part of the ileum along with air in the gallbladder .
diagnosis was made as intestinal obstruction with septicemia on basis of clinical and radiological correlations . in view of acute intestinal obstruction
, laparotomy was performed and findings revealed proximal dilated loops without any collection in the peritoneum .
a large stone of 4 cm in size was present one foot proximal to ileocaecal junction and was causing obstruction ( figure 1 ) .
the gallstone was removed through the perforation site after milking and strictureplasty were conducted ( figure 2a and 2b ) . on gross examination ,
the stone was oval in shape , hard in nature , brownish in color , and 5 cm in size ( figure 3a and 3b ) .
operative picture showing impacted stone and proximal dilated loops of the jejunum a and b. impacted stone removed from the intestine a and b. gross specimen of the stone
gallstone ileus is an uncommon complication of gallstones along with mirizzi syndrome and cholecystocholedochal fistula .
it accounts only for 1 - 4% of all causes of intestinal obstruction and up to 25% of cases of non - strangulated small - bowel obstruction in patients over 65 years of age .
the gallstone may enter the intestine through a fistulous communication between the common bile duct and the gastrointestinal tract .
however , the gallstone can impact anywhere in the gastrointestinal tract and it should be at least 2 - 2.5 cm in diameter to cause obstruction . as shown by reisner and cohen , impaction of the stone can occur at any part of the bowel including ileum ( 60.5% ) , jejunum ( 16.1% ) , stomach ( 14.2% ) , colon ( 4.1% ) , and duodenum ( 3.5% ) .
it most frequently occurs in the terminal ileum and the ileocecal valve because of their narrow lumen and potentially less active peristalsis .
the most common complications of gallstone disease are acute cholecystitis , acute pancreatitis , choledocholithiasis with or without cholangitis , and a gangrenous gallbladder .
morbidity from gallstone ileus   in the past , it was difficult to clinch the diagnosis , but the advent of ct and mri has made it easier to diagnose gallstone ileus . in 50% of cases ,
the classic rigler 's triad of radiography includes mechanical bowel obstruction , pneumobilia , and an ectopic gallstone within bowel lumen .
however , air in the gallbladder , small bowel obstruction , and gallstone ileus imply the presence of biliary enteric fistula .
the choice is between performing simple enterolithotomy with longitudinal incision on the antimesenteric border proximal to the site of obstruction , or a single - stage procedure involving enterolithotomy , cholecystectomy , and closure of the fistula .
the choice of the surgical procedure is largely determined by the clinical condition of the patient .
if the patient is hemodynamically stable , then single - stage procedure can be performed . however , in unstable patients with renal failure , enterolithotomy alone is considered sufficient ( table 2 ) .
we thus performed enterolithotomy since our patient suffered from renal failure , diabetics , and brain infarcts .
the laparoscopy - assisted techniques have been reported by sarli et al . who successfully treated three women with gallstone ileus .
however , one should remember that laparoscopy is somehow more challenging in cases of dilated and edematous bowel and may require gentle mobilization of the bowel to prevent perforation .
the final technical issues to remember are milking the stone and taking the enterotomies away from the site of impaction because it is often edematous .
in addition , resection of a segment of the bowel might be necessary if the stone is firmly fixed in an edematous and inflamed segment of bowel .
this entity should be kept in the back of mind as differential diagnosis of intestinal obstruction in patients with sonographic findings of inflammatory changes of gallbladder , especially elderly women .
the goal of treatment in gallstone ileus is early relief of intestinal obstruction and minimization of morbidity and mortality .
 background : gallstone ileus is an uncommon complication of gall stones associated with potentially serious morbidity and mortality.case report : we reported a 60-year - old male case who presented with renal failure and pain in right hypochondriac region . 
 he also had a history of brain infarcts along with diabetes which is an additional factor for mortality . on computed tomography of the abdomen , 
 he was diagnosed to have cholecystocholedochal fistula including air in the gall bladder and obstruction in the distal part of the ileum . 
 computed tomography plays an important role to make the proper diagnosis and in treatment.conclusions:as in our case , diagnosis was challengeable because of renal failure , diabetes , septicaemia and intestinal obstruction ( peritonitis ) . 
 we did surgery on the basis of peritonitis which remains the only choice in such cases . 
 in follow- up of 1 month patient was doing well and asymptomatic . 
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