SummaryThis case report illustrates the difficulties in making the clinical diagnosis of gallstone ileus. In addition to an unusual clinical picture, the changes normally expected on abdominal X-ray in gallstone ileus were subtle and missed in our patient. The diagnosis was made using abdominal computerised tomography (CT). We recommend the early use of abdominal CT scanning in the investigation of clinical bowel obstruction, especially in the elderly, where gallstone ileus is a more common condition.