The stem
A 55-year-old man has two days of abdominal pain, distension and vomiting.
CT abdomen and pelvisImages on Radiopaedia
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Case courtesy of Vikas Shah, Radiopaedia.org. View the case. Licensed CC BY-NC-SA 3.0.
The examiner’s questions
Question 1Describe the findings.Show the model answer
Branching gas in the right upper quadrant in the bile ducts (pneumobilia), dilated gas-filled small bowel loops, and a 5 cm stone in the lumen of the small bowel at the transition point. The gallbladder is thick-walled and inflamed, with a fistula to the duodenum.
Question 2What is the diagnosis?Show the model answer
Gallstone ileus: small bowel obstruction by a gallstone that has passed through a fistula between the gallbladder and the duodenum.
Question 3What is Rigler's triad, and where does the stone usually impact?Show the model answer
Pneumobilia, small bowel obstruction and an ectopic gallstone. The stone usually impacts in the terminal ileum, the narrowest part of the small bowel.
Question 4What is the management?Show the model answer
Resuscitation, then enterolithotomy: removal of the stone through an incision in the bowel above it, with a search for further stones. The fistula is usually left alone at the first operation.
After you answerThe teaching pointShow
Gallstone ileus is classically seen in elderly women. It is a mechanical obstruction, so "ileus" in its name is a misnomer.
Related: Model clerking: bowel obstruction →
Source case on Radiopaedia: “Gallstone ileus”, by Vikas Shah.
This station page is shared under CC BY-NC-SA 3.0, the licence of the Radiopaedia case it uses.