Archive Of Standardized Exam Questions: Gallstone Ileus


This page is dedicated to organizing various examples of standardized exam questions whose topic is gallstone ileus. While this may seem a odd practice, it is useful to see multiple examples of how gallstone ileus will be characterized on standardized exams (namely the boards and the shelf exams). This page is not meant to be used as a traditional question bank (as all of the answers will be the same), however seeing the classic “test” characterization for a topic is quite valuable.


When it comes to standardized exams, each topic has its own “code” marked by key buzzwords, lab findings, clues, etc. If you are well versed in this code you will be able to more quickly identify the condition that is being discussed, and get the right answer on the exam you are taking. Below is the “code” for gallstone ileus

Chief Complaints:

  • Abdominal pain: crampy/episodic in nature
  • Nausea/vomiting

Patient History:

  • Acute calculous cholecystitis (gallstones)

Clinical Workup:

  • Signs of small bowel obstruction:
    • Can be observed on physical exam (HIGH PITCHED BOWEL SOUNDS VERY SPECIFIC, abdominal tenderness, abdominal distention)
    • Can be seen on imaging (dilated loops of intestines, air/fluid levels)
  • Presence of air in biliary tree/gallbladder: VERY specific for gallstone ileus

Question # 1

A 80 year old female is brought to the ER because she has abdominal pan. She explains that she notices the pain “comes and goes” and she also has been experiencing nausea and vomiting. The patients past medical history is unknown, and she is unable to elaborate when asked about it. Her husband explains that she takes medications for type 2 diabetes, dementia, and hypertension. The patients vitals reveal a low-grade fever and slight tachycardia. An abdominal exam reveals diffuse tenderness, and high-pitched bowel sounds are auscultated. An abdominal X-ray reveals findings consistent with small bowel obstruction with the presence of air in the biliary tree. What is the likely diagnosis in this patient?

Explanation # 1

Small bowel obstruction + air in biliary tree = gallstone ileus

Question # 2

A 70 year old woman comes to the hospital because she has been experiencing abdominal cramps for the past couple of days She also companies of feeling nauseous and of vomiting twice. She denies seeing any blood in her vomit or in her stool. Her past medical history is notable for type 2 diabetes and hypertension. She also has a recent history of acute calculous cholecystitis that was managed without an operation. A physical exam reveals a distended abdomen that is tender, and has high pitched bowel sounds. An abdominal X-ray reveals air in the gallbladder and biliary tree. What is the likely diagnosis in this patient?

Explanation # 2

Crampy abdominal pain + nausea/vomiting + history of gallstones + signs of small bowel obstruction on physical exam (high pitched bowel sounds) + air in gallbladder/biliary tree = gallstone ileus

Question # 3

A 75 year old female relies in a nursing care facility. She is brought to the emergency department because she has had a fever for the past few days. She also has a recent history of vomiting. The patient is alert, however is unable to give an accurate medical history. Her temperature is currently 101.6°F and her blood pressure is 100/55 mm Hg. A physical exam is notable for a distended abdomen with occasional high-pitched bowel sounds heard. An abdominal x-ray reveals multiple dilated loops of small bowel, and the present of gas within the both the small bowel and over the area of the liver. What is the likely cause of symptoms in this patient?

Explanation # 3

Signs of small bowel obstruction on physical exam (high pitched bowel sounds) + signs of obstruction on X-ray (dilated loops of bowel) + air in liver (biliary system) = gallstone ileus

Question # 4

A 79 year old female comes to the clinic because she has been experiencing crampy abdominal pain and distention for the past few days. She also complains of nausea and vomiting. Her past medical history is otherwise unremarkable and she has no surgical history. Her vitals are currently within normal limits. A physical exam reveals abdominal distention, mild tenderness that is diffuse in nature, and high-pitched bowel sounds. An X-ray of the abdomen reveals the person of multiple air-fluid levels throughout the small bowel, and there is also air found within the liver. There is no gas found in the colon. What is the likely diagnosis in this patient?

Explanation # 4

Crampy abdominal pain + nausea/vomiting + signs of small bowel obstruction on physical exam (high pitched bowel sounds) + signs of obstruction on X-ray (air/fluid levels) + air in liver (biliary system) = gallstone ileus


Many questions on standardized exams go beyond simply recognizing the underlying topic. Often there are specific testable facts regarding some aspect of the topic’s pathophysiology/management/clinical implications that are commonly asked. Some of these are listed below:


  • General: the migration of a gallstone from the gall bladder into the GI tract (via a cholecystoenteric fistula)


  • Most likely location of stone: generally these stones will get stuck in the ileum (the narrowest portion of the intestine). The stone generally can not pass the ileocecal valve.


Page Updated: 11.29.2017