Presentation
Diffuse abdominal pain and bilious vomiting.
Patient Data
Multiple dilated bowel loops with air-fluid levels, predominantly central in location, suggestive of small bowel obstruction.
The gall bladder shows intraluminal air and contrast with connection to the first part of duodenum by cholecystoduodenal fistula.
Dilated small bowel loops till the ileum where an oval radiolucent lamellated structure is seen, in keeping with small bowel obstruction mostly by a large gallstone.
The distal ileum and colon are collapsed. No bowel wall thickening or pneumatosis intestinalis noted.
Duodenal diverticulum at third part of duodenum is also noted.
Case Discussion
The obstructing gallstone was hard to be identified on CT due to minimal calcification, and in plain erect radiographs it was harder due to increased body mass of the patient also. Here, the diagnosis was difficult to suspect on plain radiograph due to absence of pneumobilia and calcified gallstone in the presence of bowel obstruction (Rigler triad). Generally, the stone tends to be large, and typically seen in the right iliac fossa.