Image of the Month—Quiz Case | Emergency Medicine | JAMA Surgery | JAMA Network
[Skip to Navigation]
Sign In
Special Feature
December 1, 2003

Image of the Month—Quiz Case

Author Affiliations

From the Department of Surgery, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin, Ireland.



Arch Surg. 2003;138(12):1391. doi:10.1001/archsurg.138.12.1391

AN 87-YEAR-OLD man with a known history of cholelithiasis was seen in the emergency department for acute onset of abdominal pain, vomiting, and diarrhea. On examination, he was afebrile, had a distended abdomen, and was tender to palpation in the left iliac fossa. Bowel sounds were active. The abdominal computed tomographic scan is shown in Figure 1. Following unsuccessful attempts at endoscopic fragmentation/extraction, a small left iliac fossa muscle-splitting incision was performed, the stone removed (Figure 2), and a colostomy formed.

What Is the Diagnosis?

A. Diverticular stricture

B. Cholecystocolic fistula and large-bowel obstruction due to gallstone ileus

C. Cholecystoduodenal fistula and small-bowel obstruction due to gallstone ileus

D. Obstructing colonic carcinoma

Corresponding author: Gerrard O'Donoghue, AFRCSI, Department of Surgical Research, Education and Research Centre, Beaumont Hospital, Dublin 9, Ireland (e-mail: