Atypical Proximal Gallstone Ileus Near the Ligament of Treitz Managed With Staged Surgical Intervention: A Case Report.

Gallstone ileus is a rare mechanical bowel obstruction caused by the migration of a gallstone through a biliary-enteric fistula, most commonly impacting at the ileocecal valve. Proximal obstruction is uncommon and is typically classified as Bouveret syndrome when involving the stomach or proximal duodenum. Obstruction near the ligament of Treitz represents an exceedingly rare variant. A 76-year-old female presented with nausea, vomiting, and abdominal distention. Computed tomography demonstrated gastric and proximal small bowel dilation secondary to an obstructing gallstone in the distal duodenum. After anticoagulation reversal, exploratory laparotomy was performed. The stone was manually advanced into the jejunum, followed by segmental resection and primary anastomosis. The gallstone measured 6 cm. The gallbladder and fistula were not addressed initially. The patient recovered well and was discharged on postoperative day four. She later underwent an elective robotic cholecystectomy with fistula takedown without complication. This case describes an atypical proximal gallstone ileus located near the ligament of Treitz, distinct from both classic gallstone ileus and Bouveret syndrome. A staged surgical approach allowed safe relief of obstruction followed by definitive biliary management. This case highlights the importance of individualized surgical planning and supports staged management as a safe and effective strategy for rare proximal gallstone ileus.