A patient with gallstone ileus associated with two separate biliary-enteric fistulae has been reported. The patient had exploratory laparotomy with removal of the gallstone from the distal ileum, repair of the two fistula tracts, and cholecystectomy. The pathology report showed adenocarcinoma of the gallbladder. The patient was discharged 14 days after surgery. It is important to point out that the diagnosis was not suspected prior to surgery, although the patient was elderly with known cholelithiasis, no prior abdominal surgery, and clinical symptoms of bowel obstruction. The plain abdominal film showed a partial small bowel obstruction pattern with a pair of air-fluid levels in the right upper quadrant, no air in the biliary tract, and no visible calculus. When there is a clinical suspicion of gallstone ileus and the plain abdominal film is not diagnostic, there are several modalities available that have been proven to be useful (ie, contrast medium examinations, ultrasound, and hepatobiliary scan).