286 Gallstone Ileus with Sealed Perforation of a Jejunal Diverticulum: Why Clinical Suspicion and Intraoperative Judgment Trump Imaging Findings

Abstract Introduction Gallstone ileus is a rare complication of cholelithiasis, responsible for 1–4% of small bowel obstructions. Impaction of the stone in the jejunum is exceptionally uncommon. This case report highlights a rare presentation of gallstone ileus complicated by sealed perforated jejunal diverticulum, presenting a diagnostic and therapeutic challenge. Case Presentation A 61-year-old male presented with progressive abdominal pain, bilious vomiting, and abdominal distension. Examination revealed a distended, tender abdomen with exaggerated bowel sounds. Initial CT interpretation suggested adhesive small bowel obstruction without intraluminal pathology. However, review of the images identified a hyperdense lesion consistent with an ectopic gallstone, raising suspicion for gallstone ileus and prompting operative management. Intraoperatively, a large gallstone was found impacted in the jejunum approximately 2.5 meters from the duodenojejunal flexure, with evidence of extensive jejunal diverticulosis and a sealed perforation. The patient underwent segmental resection of the jejunum and side-to-side hand-sewn anastomosis. He developed postoperative ileus, which was managed conservatively, and was discharged in good condition on postoperative day 11. Discussion This case illustrates a rare form of gallstone ileus in the setting of enteric diverticulosis, complicated by sealed perforation. high clinical suspicion is required to diagnose gallstones ileus when history of gallstones and classical imaging findings are not present. Segmental resection was required due to local inflammation and potential perforation, highlighting the importance of intraoperative judgement. Conclusions Gallstone ileus, though rare, should be considered in patients with small bowel obstruction, even when classical imaging findings are absent. Enteric diverticulosis may complicate such cases and may warrant surgical resection.