A 70-year-old woman presents with 3 days of distension, vomiting, and obstipation. She has a long history of symptomatic gallstones that she declined surgery for. Abdominal radiograph shows dilated small bowel loops, gas in the biliary tree, and a calcified opacity in the right iliac fossa. The most likely diagnosis is:

• A Emphysematous cholecystitis
• B Gallstone ileus ✓
• C Cholangitis with adynamic ileus
• D Sigmoid volvulus

Explanation

Rigler's triad of pneumobilia, small bowel obstruction, and an ectopic gallstone is diagnostic of gallstone ileus, caused by a large stone eroding through a cholecystoenteric fistula, classically into the duodenum, then impacting at the narrow terminal ileum. Emphysematous cholecystitis causes pneumobilia-adjacent gas but not mechanical obstruction. Management is relief of the obstruction by enterolithotomy rather than fistula repair in the acute setting.

Reference: Bailey and Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.