Giant Gallstone Ileus With Concomitant Mesenteric Torsion and Severe Acute Kidney Injury in an Elderly Woman: A Case Report

Gallstone ileus is an uncommon mechanical cause of small bowel obstruction.It typically results from a gallstone migrating through a cholecystoenteric fistula and impacting at the ileocecal valve, the narrowest point of the small bowel.Jejunal impaction occurs in a minority of cases and is considered atypical.We report a 74-year-old woman with poorly controlled type 2 diabetes mellitus who presented with a 5-day history of generalized abdominal pain, nausea, and vomiting.On admission, she already had stage three acute kidney injury (AKIN III) and moderate hypo-osmolar hyponatremia, both attributable to prolonged vomiting and volume depletion.Nasogastric decompression yielded approximately 2,600 mL of fecaloid material, and contrast-enhanced computed tomography demonstrated pneumobilia together with an ectopic intraluminal foreign body, prompting a diagnosis of intestinal obstruction secondary to gallstone ileus.Exploratory laparotomy revealed a stone measuring approximately 10x8x6 centimeters impacted in the ileum, 200 centimeters distal to the ligament of Treitz, along with incidental 180° mesenteric torsion without vascular compromise.Enterolithotomy with primary two-layer closure and an incidental appendectomy were performed without takedown of a cholecystoenteric fistula, given the patient's age and comorbidities.A postoperative abdominal ultrasound obtained to investigate a second episode of worsening renal function unexpectedly described an absent gallbladder attributed to prior surgery, a detail that had not been captured on admission and raises the possibility of unrecognized post-cholecystectomy gallstone ileus.Renal function trended toward baseline, and the patient was discharged on postoperative day four with outpatient follow-up arranged.This case brings together three uncommon features: a giant ileum gallstone, concurrent mesenteric torsion, and severe acute kidney injury at presentation, and illustrates how imaging can surface surgical history that an elderly patient may not report accurately.