Bowel hath no fury like a gallbladder inflamed

Abstract

Gallstone ileus is a well-established phenomenon in which a large gallstone leads to mechanical small bowel obstruction. This case, however, reports the novel finding of a patient presenting with suprapubic pain and guarding caused by paralytic ileus of the small bowel and a duodenal perforation secondary to a necrotic gallbladder. It highlights the importance of distinguishing between gallstone ileus and paralytic ileus and how the management of the two conditions differs. Furthermore, this article discusses how paralytic ileus caused by intra-abdominal inflammatory conditions such as cholecystitis can mask the typical clinical findings making the diagnosis difficult.

Figure 1:

Plain film of the chest and abdomen: the chest X-ray shows features suggestive of air under the diaphragm, while the abdominal film shows dilated loops of small and large bowel with air in the rectum, highly suggestive of ileus.

Figure 2:

CT abdomen + pelvis: (a) inflammation of the gallbladder and (b) a very closely adherent gallbladder to the second part of the duodenum (D2).