Snapshot An 85-year-old woman with a history of hypertension presents to the emergency department with one-week of nausea, vomiting, and crampy, intermittent right upper quadrant abdominal pain. On physical exam, mucous membranes are dry and the RUQ abdomen is tender to palpation. Abdominal radiograph reveals dilated loops of small bowel and gas in the biliary tree. Surgery is consulted for urgent laparotomy and enterotomy. Introduction A mechanical obstruction of the bowel by a large gallstone caused by cholecystenteric fistula which connects the gallbladder with the duodenum or the hepatic flexure most common site is ileocecal valve Gallstone ileus is most commonly seen in elderly women with a chronically inflamed gallbladder that adheres to the wall of the intestine Presentation Symptoms bowel obstruction nausea vomitting failure to pass stool abdominal pain may be seen in severely ill patients with altered mental status who may not be able to localize pain Physical exam nonspecific Evaluation Abdominal radiograph small bowel obstruction (dilated loops of bowel) free air in the gallbladder (pneumobilia) Upper GI barium contrast absence of contrast in colon helps identify location of fistula and level of obstruction Abdominal ultrasound helps identify location of gallstones also more sensitive for detecting pneumobilia Treatment Emergent laparotomy and enterotomy Consider cholecystectomy and fistula repair in select populations who can tolerate longer surgical procedure, may reduce risk of complications and potential need for reintervention