• diabetes mellitus
• gall stone ileus
• intestinal obstruction

A 82 year old white woman was admitted with a history of heartburn nausea and vomiting of three days’ duration. She also complained of pain in her lower abdomen. She was being treated for type 2 diabetes mellitus, hypertension, and atrial fibrillation. Her medication consisted of metformin, tolbutamide, digoxin, aspirin, and bendrofluazide. She had previously had an ultrasound scan of her abdomen that incidentally showed biliary stones, but there was no previous history of biliary colic. She had no previous history of abdominal surgery. On admission she was nauseated and had bilious vomiting. Her pulse rate was 81 beats/min, irregularly irregular, blood pressure was150/86 mm Hg, core temperature was raised at 38C, and there was no pallor or icterus. The abdomen was distended with tenderness in left inguinal fossa but there was no guarding or rigidity. The bowel sounds were exaggerated. Rectal examination revealed an empty rectum. The rest of the examination was within normal limits. Investigations showed a normal haemoglobin concentration but raised white cell count with predominant neutrophilia. Renal and liver function tests were within normal limits. Serum glucose was raised at 16 mmol/l. An electrocardiogram showed atrial fibrillation with a heart rate of 95 beats/min. Her abdominal radiograph is shown below (fig 1). The patient was diagnosed with acute intestinal obstruction and was kept nil by mouth, started on intravenous broad spectrum antibiotics, and a nasogastric tube was placed with free drainage pending computed tomography of the abdomen (fig 2).

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Figure 1

Plain radiograph.

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Figure 2

Computed tomogram.