Elderly patient with prior laparotomy and incisional hernia repair now presents with abdominal pain, distention, nausea and vomiting.
Erect and supine abdominal x-rays demonstrate a number of prominent air-fluid levels located within dilated loops of small bowel. In addition branching lucency is visible near the liver hilum. A faint rounded calcified density is visible to the left of the midline, projecting to the side of the L3/4 disc space and above the iliac crest.
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Branching lucency in the right upper quadrant (green arrows) and a faint peripherally calcified opacity to the left of the midline (blue arrows) are fisible, in addition to multiple air fluid levels (orange lines).
The patient went on to have the inevitable CT scan, although the correct diagnosis had already been made by the radiologist.
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C+ portal venous phase
In the mid portion of the small bowel, to the left of the midline a 3cm peripherally calcified intraluminal mass is seen at the point of transition between dilated fluid filled proximal small bowel, and collapsed distal small bowel.
Gas is confirmed to be present at the liver hilum, confined to the biliary tree.
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Calcified gallstone (blue dotted line) is the cause of a small bowel obstruction, with markedly dilated loops extending proximally from it. Pneumobilia is evident at the hepatic hilum (green arrows).
There is evidence of a previous abdominal hernia repair (yellow arrows).
Abdominal films are often no longer obtained in the setting of acute abdominal pain, with most patients proceeding directly to CT. It is true that if the patient is unwell enough, plain films are unlikely to make a CT unnecessary. Even so, in this case, supine and abdominal films were sufficient to make the diagnosis. Although no one believes plain films anymore, gallstone ileus remains a favourite case for oral exams.