Gallstone ileus

Case contributed by Julia Voitovich
Diagnosis almost certain

Presentation

3 days of abdominal pain and distension and vomiting.

Patient Data

Age: 60 years
Gender: Female
ct

On the scout view, gas is visible in a crescentic shape in the right upper quadrant, as well as more linear gas over the expected position of the liver. Multiple dilated loops of small bowel also noted. 

The CT images show thickening of the gall bladder wall with a cholecystoduodenal fistula, and consequent gas within the biliary system. Small bowel obstruction is noted, with multiple fluid-filled loops of small bowel with a transition point in the pelvis where a partially calcified intraluminal structure causes obstruction. The small bowel distal to this point is collapsed. Mesenteric edema and congestion is present, with no collection of perforation.

There are incidental findings of bilateral renal cysts, as well as a large right sided ovarian cyst.

Case Discussion

This case shows classic features of gallstone ileus, with the scout image being the modern equivalent of the plain abdominal radiograph. Gallstone ileus occurs due to chronic inflammation of the gallbladder, resulting in formation of a fistula to the adjacent duodenum. This accounts for the pneumobilia. Gallstone passage into the small results in small bowel obstruction when the stone can no longer continue in its journey. The three findings of Rigler's triad are seen on the CT - pneumobilia, small bowel obstruction and an ectopic calcified gallstone. In this case, there is subtle gallstone calcification, which makes the stone easier to identify. However, not all gallstones will calcify and so instead the transition point may help locate the gallstone.

Case uploaded with the assistance of Dr Vikas Shah.

How to use cases

You can use Radiopaedia cases in a variety of ways to help you learn and teach.

Creating your own cases is easy.