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Findings in this case: 1) The gallbladder wall is thickened. There is increased attenuation material present within the gallbladder. 2) There is air within the gallbladder as well as air within the common duct. 3) There is a mild small bowel obstruction particularly involving the distal small bowel loops in the lower abdomen and pelvis. The focus of the obstruction is seen beginning on images 88 and extending through approximately image 100. This represents a partially calcified gallstone.
Diagnosis: Gallstone ileus
File: 4D.
Organ system: 4. Hepatobiliary tract.
Organ: D. Gallbladder.
Etiology and incidence: 1) This is actually a misnomer and is a small bowel obstruction secondary to a gallstone impaction. 2) Typically occurs with evidence and symptoms of chronic cholecystitis.
Diagnosis: 1) Clinical: Clinical symptoms are those of small bowel obstruction. Clinically, middle-age or older white female with recurrent RIGHT upper quadrant pain now presenting with more significant abdominal pain and vomiting. 2) Imaging: A) The classic diagnosis is Rigler’s triad which is: Air in the biliary tract, small bowel obstruction and evidence of a gallstone within the bowel. B) There are 3 classic points for obstruction, the duodenum, the area of the ligament of Treitz and ileocecal valve within the small bowel. Within the colon, the sigmoid colon is also a potential site for obstruction. C) Gallstone is typically greater than 2 to 2.5 cm in size.
Differential diagnosis: 1) Other causes for small bowel obstruction. 2) Changes secondary to ERCP and/or sphincterotomy causing air within the biliary system. 3) Elongated gallbladder with a gallstone in the fundus extending into the mid or RIGHT lower quadrant area. 4) Gallstone or other calcifications within the peritoneal cavity. 5) A “dropped gallstone” occurs secondary to laparoscopic cholecystectomy most commonly.
Prognosis: 1) Similar to that of any small bowel obstruction. The stone is usually impacted and requires surgery to remove a gallstone in the obstruction. 2) There may or may not be a persistent fistula which may need resection as well.
References:
Gallstone ileus http://www.uptodate.com/contents/gallstone-ileus
Gallstone Ileus http://www.learningradiology.com/archives05/COW%20150-
Gallstone Ileus http://www.nejm.org/doi/full/10.1056/NEJMicm0809541
Gallstone Ileus http://www.diagnosticimaging.com/case-studies/content/article/113619/1876150
