Introduction: Gallstone ileus is an anatomical mechanical obstruction of the small bowel that is induced by a gallstone also known as gallstone ileus. The pathophysiology includes the migration of a gallstone out of the gallbladder, where the pressure of the stone can create a passage, such as a cholecystoenteric fistula, and can therefore result in SBO. Case Description/Methods: A 74-year-old female presented to the emergency department complaints of 3 day history of nausea, vomiting, left lower quadrant pain, bloating & flatus. Patients vomiting was un-relenting despite electrolytes and OTC medications. On presentation she had significant left upper quadrant tenderness and hypoactive bowel sounds. She had a low-grade temperature; with stable vitals. Labs & Imaging: AST 22 U/L, ALT 19 U/L, Total Bilirubin 0.5 mg/dL, ALP 134 U/L, WBC 12.46 10^3/uL. Image: CT of the abdomen/pelvis without contrast showed “mid to distal small bowel obstruction most likely secondary to gallstone ileus”. Management & post-surgery: IVFs, NPO and Anti-emetics. GI consulted and Surgery consulted. Laparoscopic assisted enterotomy and removal of 3.5 cm gallstone with primary repair of small bowel enterotomy lysis of adhesions. The dilation of the bowel significantly improved thereafter, and the patient tolerated the procedure well. Specimen analysis confirmed findings as gallstone. 3 months post-surgery patient has been doing well with no further complications or surgical interventions. Discussion: Less than 1% of intestinal obstruction are derived from this etiology[1]. A review of Gallstone ileus cases across the nation from 2004-2009 indicated that the incidence is only 0.095%[2]. The associated mortality rate is around 15-18%[3]. Cholesterol gallstone created a fistula allowing air to enter the biliary tree, classic presentation of Rigler’s triad: pneumobilia, small bowel obstruction, and a gallstone 5. This is more of an anatomical obstruction rather than an actual ileus. The surgical approach of the obstruction is the mainstay of the treatment: (1) simple enterolithotomy; (2) enterolithotomy, cholecystectomy and fistula closure; and (3) enterolithotomy with cholecystectomy performed later 1. The biggest controversy in the past has been, if a biliary surgery be carried out at the same time or at a later stage. In this patient management with simple enterolithotomy was proven successful.Figure 1:: CT images of Gallstone Ileus and Gross Appearance of Gall stone