CASE REPORT Asian J Gerontol Geriatr 2018; 13(2): 80–2 | DOI: 10.12809/ajgg-2017-285-cr 80 © 2018 The Hong Kong Geriatrics Society and Hong Kong Association of Gerontology. CC BY-NC-ND 4.0 Gallstone ileus in geriatric patients: a report of two cases Ismail Burud 1 , MBBS, MS, Ravindranath Shroff 1 , MS FRCS, Mahadevan Tata 2 , MBBS, MS ABSTRACT Gallstone ileus is a mechanical obstruction of the small intestine caused by gallstone impaction. It accounts for 1% to 4% of all cases of mechanical obstruction. Previous acute cholecystitis results in development of a fistula between the gallbladder and the gastrointestinal tract. Diagnosing gallstone ileus is difficult as symptoms and signs are non-specific and most patients are elderly with multiple comorbidities. We report two cases of gallstone ileus in elderly patients. The first case is a 72-year- old man with multiple comorbidities who presented with vomiting, intermittent colicky right-sided abdominal pain, and inability to pass motion. He underwent enterolithotomy alone. The second case is a 73-year-old woman who presented with abdominal pain, distension, fever, and a fistulous communication between the gallbladder and the duodenum. She underwent enterolithotomy, partial cholecystectomy, and closure of the fistula. Key words: Gallstone; Ileus 1 Department of Surgery, International Medical University, Seremban, Malaysia 2 Hospital Tuanku Jaafar, Jalan Rasah, Seremban, Negri Sembilan, Malaysia Correspondence to: Ismail Burud, Senior Lecturer, Department of Surgery, International Medical University, Seremban, 70300, Malaysia. Email: mohammedburud@hotmail.com CASE REPORTS Patient 1 In June 2015, a 72-year-old man with hypertension, beta thalassaemia, and end-stage renal failure presented with vomiting (>10 times a day for 3 days), intermittent colicky right-sided abdominal pain, and inability to pass motion. On examination, he was mildly dehydrated with a soft non-distended abdomen and no palpable mass. His electrolyte levels were deranged and creatinine level was elevated and required dialysis. Radiography of the abdomen showed a dilated small bowel. Computed tomography of the abdomen revealed the presence of pneumobilia within the common bile duct and intrahepatic duct, and a fistula between the gallbladder and a large calculus within the small bowel at the jejunoileal junction (FIGURE 1). Emergency laparotomy and enterolithotomy were performed, and a stone (2x2 cm) was removed 20 cm from the ileocecal junction. Postoperatively, the patient recovered well. INTRODUCTION Gallstone ileus is a rare complication of cholelithiasis and accounts for 25% of non-strangulated small intestinal obstruction. 1 It is a surgical emergency in elderly patients who usually present with non-specific symptoms such as abdominal pain, distension, nausea, and vomiting. 2,3 Bilio-enteric fistula is caused by recurrent inflammation secondary to cholelithiasis, with cholecystoduodenal fistula more common than cholecystocolonic fistula (89% vs 11%). 3,4 Most patients are older women with multiple comorbidities, and the mortality is high (10% to 18%). 1,5 Radiography, ultrasonography, and computed tomography of the abdomen are important tools for diagnosis. Surgical options remain controversial in terms of whether to perform a single-stage or two-stage procedure for enterlithotomy, stone removal with cholecystectomy, and repair of fistula. Enterlithotomy alone is a suitable option for patients who are unstable and have multiple comorbidities.