A 70-year-old woman presents with 3 days of distension, vomiting, and obstipation. Abdominal radiograph shows dilated small bowel loops with gas in the biliary tree and a radio-opaque shadow in the right iliac fossa. She has a long history of untreated gallstone disease. The most likely diagnosis is:
- A Emphysematous cholecystitis
- B Sclerosing cholangitis with ileal obstruction
- C Gallstone ileus secondary to cholecystoduodenal fistula ✓
- D Retroperitoneal duodenal perforation
Correct answer: C. Gallstone ileus secondary to cholecystoduodenal fistula
Explanation
The combination of small bowel obstruction, pneumobilia, and an ectopic calcified stone is Rigler's triad, the classic radiographic picture of gallstone ileus. It results from a large stone eroding through the gallbladder wall into the duodenum and impacting at the narrowest point of the small bowel, usually the terminal ileum. Emphysematous cholecystitis causes gas in the gallbladder wall, not the biliary tree, and does not cause mechanical small bowel obstruction.
Reference: Bailey and Love's Short Practice of Surgery, 27th ed.
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Written and medically reviewed by the StethoPrep medical team.