Multiple gallstones causing ileus twenty years after cholecystectomy

Gallstone ileus is an important form of small bowel obstruction that occurs in less than 0.5% of patients who present with obstruction. A biliary enteric fistula that evolves in the setting of chronic cholecystitis may allow the passage of a large gallstone into the gastrointestinal tract distal to the common duct. A single stone that is sufficient in size (at least 2-2.5 cm diameter) may then create a mechanical obstruction, most often at the ileocecal valve or the terminal ileum where the intestinal lumen narrows, and where peristalsis is less robust. We present an unusual case of gallstone ileus in a patient whose obstruction was caused by not one, but seven individual gallstones, collectively restricted in the jejunum at the point of a previous anastomosis and occurring twenty years after cholecystectomy.