Presentation
Two days of abdominal pain, distension and vomiting.
Patient Data
Branching gas in the right upper quadrant. Gas-filled and dilated small bowel loops.
There is gas within the intra- and extra-hepatic biliary tree. The gall bladder and adjacent duodenum are thick walled and inflamed with a fistula between the two structures. The small bowel is distended and there is a 5 cm stone in the lumen at the transition point. No other similar intraluminal filling defects are noted.
Incidental findings include an area of rounded atelectasis in the left lower lobe, cardiomegaly, bilateral inguinal hernia and an enlarged prostate.
Case Discussion
The scout film from the CT shows 2 of the 3 components of the Rigler triad: pneumobilia and small bowel obstruction. The CT shows the third component: a gallstone at the site of obstruction. Chronic cholecystitis leads to a cholecystoduodenal fistula and migration of gallstone(s) into the small bowel where they may cause obstruction if large enough. It is important to avoid satisfaction of search and thoroughly examine the small bowel for any additional stones such that they can all be retrieved during surgery. A single stone was successfully retrieved in this case with an uneventful recovery.
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