Gallstone ileus Quiz: Ace Your Exams

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A 72-year-old woman comes to the emergency department because of intermittent crampy abdominal pain associated with nausea and vomiting for the last five days. She had an episode of vomiting with hematemesis six hours ago. Past medical history is significant for diabetes mellitus, gallstones, and hypertension. Current medications are metformin and lisinopril. Temperature is 38.2°C (100.8°F), pulse is 118/min, respirations are 22/min, and blood pressure is 110/60 mm Hg. Abdominal examination shows distention and tenderness, and hyperactive high-pitched bowel sounds are heard on auscultation. An abdominal radiograph shows pneumobilia and dilated loops of small bowel. Laboratory results are shown below:  
 
 Laboratory value Result 
Leukocyte count  23,250/mm3 
 Hemoglobin  12 g/dL 
 Hematocrit  46% 
 Platelets  400,000/µL 
 Lipase  140 U/L 
 AST, SGOT  47 U/L 
 ALT, SGPT  45 U/L 
 Total bilirubin  0.8 mg/dL 
Which of the following is the most likely underlying cause of this patient's presentation? 

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