Diagnosis and treatment of a patient with gallstone ileus.

BACKGROUND: A 79-year-old white woman presented with upper abdominal pain. She had a history of rheumatoid arthritis since she was 19 years old, which was treated with prednisolone, leflunomide, diclofenac and pantoprazole. She also had factor VII deficiency. The patient had been hospitalized 2 months previously with sepsis presumed to be due to urinary infection, and was treated with antibiotics. Sonography at this time revealed a gallbladder with a monstrous thick wall and stones, and the first differential diagnosis was cholecystitis. Cholecystectomy was planned after amelioration of the patient's general state, but her general state worsened. INVESTIGATIONS: Sonography, endoscopy of the upper and lower intestine, and CT scan. DIAGNOSIS: Biliodigestive fistula and gallstone ileus. MANAGEMENT: Enterolithotomy, stenting, endoscopic retrograde cholangiopancreatography, and surgery.