Gallstone ileus with the classic Rigler\'s triad

Clinical History

A 81-year-old woman presented to emergency room with diffuse abdominal pain, nausea, vomiting and constipation.

Imaging Findings

An abdominal plain radiograph (Fig. 1) was performed in which a calcified rounded structure located in the left flank and small bowel dilatation were seen. The patient also underwent an abdominal computed tomography examination (Fig. 2, 3) which showed aerobilia, small bowel dilatation, fistula between the gallbladder and the duodenum and a stone inside a jejunum loop. The patient was diagnosed of gallstone ileus and the stone was surgically removed by an enterolithotomy.

Discussion

Gallstone ileus is a mechanical obstruction of the bowel secondary to a gallstone impacted within the gut. It is frequently seen in elderly patients with history of cholelithiasis or cholecystitis. [1, 2] The adhesion of the gallbladder next to the small bowel can develop a fistula with migration of gallstones into the lumen of the bowel. It accounts for 1-2 % of mechanical small bowel obstruction and in geriatric population, the incidence increases to 25%. [3]
As the clinical symptoms are mostly non-specific and they are frequently intermittent, misdiagnosis is common and it increases complications with a high morbidity and mortality. Early diagnosis is important in order to avoid complications. [3]
Gallstone ileus clinically manifests as abdominal pain, nausea, vomiting, fever, distension and constipation and the presence of the Rigler’s triad is nearly pathognomonic of gallstone illeus. Rigler’s triad consists in small bowel obstruction, gas in the biliary tree (aerobilia) and presence of ectopic gallstone. However, Rigler’s triad is present in less than 50 % of the patients with gallstone ileus. [1, 2]
Plain abdominal radiographs are quite helpful in diagnosing intestinal obstruction and, occasionally, gallstone ileus when the stone that causes the obstruction is seen. However, they have a limitation because most gallstones are not sufficiently dense to be detected. CT scans and ultrasound are more efficient than plain radiograph alone because they may also detect the specific location of an impacted stone, the site of the fistula and the site of small bowel obstruction. [2, 3, 4]
The management of patients with gallstone ileus must be individualized. Surgical treatment can either be enterolithotomy with or without cholecystectomy, or one-stage enterolithotomy, cholecystectomy and repair of the fistula. [4, 5]
It appears that majority of the patients presenting with gallstone ileus will benefit from relief of the obstruction by enterolithotomy alone in the emergency setting. One-stage procedure should be offered to highly selected patients. [4, 5]

Differential Diagnosis List

Final Diagnosis

Gallstone ileus

URL:	https://www.eurorad.org/case/13378
DOI:	10.1594/EURORAD/CASE.13378
ISSN:	1563-4086