title: Karewsky syndrome: A case report and review of the literature.
abstract: BACKGROUND
  Gallstone ileus can be a lethal disease, rarely suspected in the clinical scenario. It represents about 25% of all bowel obstruction cases in patients older than 65. There is a classification of gallstone ileus based on the onset time: acute, subacute and chronic (Karewsky syndrome). We describe the first reported case of chronic gallstone ileus.
  
  
  METHODS
  A 78-year-old female was admitted to the ER with a 15-day case of consistent bowel obstruction. The subject reported a five-year history of recurrent hospital admissions that resolved spontaneously after non-surgical management. Karewsky syndrome was diagnosed and managed with enterolithotomy. After five days of postoperative evolution the patient was discharged, and at six months follow up, no other hospital admission or relapse has been registered.
  
  
  CONCLUSIONS
  The gallstone ileus diagnosis demands a higher clinical suspicion, there is no biochemical marker, and an abdominal CT is ideal for imaging-based diagnosis. There is no consensus on the optimal surgical approach.
  
  
  CONCLUSIONS
  We describe the first case of Karewsky syndrome and a gastro-jejune and gastric-choledochus double fistula. We emphasize the importance of higher clinical suspicion for patients with bowel obstruction older than 65 years old and make evident that although there are not evidence-based guidelines for this treatment, enterolithotomy is a recommended approach.
authors.affiliation: Residente de cirugía general del Hospital Civil de Guadalajara "Dr. Juan I. Menchaca", Mexico.
authors.forename: César Felipe
authors.initials: CF
authors.lastname: Ploneda-Valencia
authors.affiliation: Residente de cirugía general del Hospital Civil de Guadalajara "Dr. Juan I. Menchaca", Mexico.
authors.forename: Victor Hugo
authors.initials: VH
authors.lastname: Sainz-Escárrega
authors.affiliation: Médico Pasante del Servicio Social, Guadalajara, Jalisco, Mexico.
authors.forename: Mariana
authors.initials: M
authors.lastname: Gallo-Morales
authors.affiliation: ME en cirugía general jefe del Servicio de Cirugía General del Hospital Civil de Guadalajara "Dr. Juan I. Menchaca", Mexico.
authors.forename: Eliseo
authors.initials: E
authors.lastname: Navarro-Muñiz
authors.affiliation: ME en cirugía general adscrito al Servicio de Cirugía General del Hospital Civil de Guadalajara "Dr. Juan I. Menchaca", Mexico.
authors.forename: Carlos Alfredo
authors.initials: CA
authors.lastname: Bautista-López
authors.affiliation: ME en cirugía general adscrito al Servicio de Cirugía General del Hospital Civil de Guadalajara "Dr. Juan I. Menchaca", Mexico.
authors.forename: Jesús Alonso
authors.initials: JA
authors.lastname: Valenzuela-Pérez
authors.affiliation: ME en cirugía general jefe de la División de Cirugía del Hospital Civil de Guadalajara "Dr. Juan I. Menchaca", Mexico. Electronic address: lopezlizarraga43@yahoo.com.mx.
authors.forename: Carlos René
authors.initials: CR
authors.lastname: López-Lizárraga
keywords: Gallstone ileus; Karewsky syndrome; Small bowel obstruction