Clinical Cases : Suddenly Worsened Abdominal Pain in a 77-Year Old Man

77-year old man, presented in the early morning with severe generalized abdominal pain for 4 hours. He started feeling "cramp-like" abdominal pain and billous vomiting yesterday, and went away. In the late evening, he had a sudden onset of severe, generalized, constant abdominal pain.

He used to have infrequent episodic abdominal pain after meals for several months, for which he describes as "going to his right upper back", and associated with intermittent vomiting.

Past medical history of hypertension, ischemic heart disease, COPD and gout.

On examination, patient is lying quite still. Abdomen is mildly distended. On palpation, there was tenderness to all four quadrants and board-like rigidity.

X-ray shows :

What is the likely index pathology responsible for this patient’s current problems?

Hint: Review the patients previous medical history and the chronology of the symptoms in his presentation.

a) Cholelithiasis
b) Peptic ulcer disease
c) Intestinal adhesions
d) Chronic pancreatitis

Answer : Cholelithiasis

Patient has mechanical small bowel obstruction complicated by perforation and subsequent peritonitis.

Why? His history is consistent with the sequence of events. Furthermore, we can see on the X-rays : (1) air under diaphragm, (2) dilated loops of small bowel.

The patient was sent for emergency laparotomy after resuscitation.

Take home messages :

- usually patients with cholelithiasis presents with biliary colic, and this kinda extra-biliary presentations are rare. However, 3-5% of patients with cholelithiasis will have some sort of cholecyst-enteric fistula. Gallstones can now take the highway to your intestines!

- And with that, comes symptoms of mechanical obstruction, depending on where the gallstone in the intestine gets "stuck" (impacted). Many times, it gets stuck for a while, and then gets dislodged and pushed along the intestines again.

- As the gallstone travel through the intestine, it gets bigger and bigger by because of acquiring sendiments from the bowel, and gets stuck again and again.

- It may really obstruct the bowel when it reaches the terminal ileum.

- Imaging can help you diagnose this disease early. Just remember the Rigler triad (pneumobilia, small-bowel obstruction, and gallstone in right iliac fossa). However, Rigler triad can only be seen 15% of the time on X-ray, 11% on ultrasound, but a freaking 78% on CT-scan. Heck, CT will even show you the fistula.

- management for any cause of intra-abdominal free air with peritonitis is always emergency laparatomy.

(http://cme.medscape.com/viewarticle/714983)