A 62-year-old woman presents with 3 days of distension, vomiting and absolute constipation. She has had recurrent right hypochondrial pain for years. Abdominal radiograph shows dilated small bowel loops, gasless lower abdomen, and pneumobilia. The most likely diagnosis is:

• A Cholangiocarcinoma with duodenal obstruction
• B Emphysematous cholecystitis with ileus
• C Gallstone ileus ✓
• D Post-inflammatory duodenal stricture from chronic cholecystitis

Explanation

The combination of small bowel obstruction, pneumobilia and an ectopic or gasless pattern constitutes Rigler's triad, classic for gallstone ileus. C large stone erodes through the chronically inflamed gallbladder wall into the duodenum, forming a cholecystoduodenal fistula, and the stone impacts usually at the terminal ileum, the narrowest point. Emphysematous cholecystitis causes portal venous gas and systemic toxicity rather than mechanical obstruction. Treatment is relieving the impaction by enterolithotomy; fistula closure is not routine.

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

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.