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Paper 2
Published in Amanda Rabone, Benedict Thomson, Nicky Dineen, Vincent Helyar, Aidan Shaw, The Final FRCR, 2020
Amanda Rabone, Benedict Thomson, Nicky Dineen, Vincent Helyar, Aidan Shaw
Gallstone ileus has the classic radiographic triad of bowel obstruction, pneumobilia and a radiopaque intraluminal gallstone; however, the so-called Rigler’s triad is only seen in 10% of cases. It occurs due to fistulation of the stone through the gallbladder wall into the bowel, most commonly the duodenum and rarely, into the colon. The gallstone most commonly obstructs at the terminal ileum.
Intestinal obstruction
Published in Professor Sir Norman Williams, Professor P. Ronan O’Connell, Professor Andrew W. McCaskie, Bailey & Love's Short Practice of Surgery, 2018
Professor Sir Norman Williams, Professor P. Ronan O’Connell, Professor Andrew W. McCaskie
This type of obstruction tends to occur in the elderly secondary to erosion of a large gallstone directly through the gall bladder into the duodenum. Classically, there is impaction about 60 cm proximal to the ileocaecal valve. The patient may have recurrent attacks as the obstruction is frequently incomplete or relapsing as a result of a ball-valve effect. The characteristic radiological sign of gallstone ileus is Rigler’s triad, comprising: small bowel obstruction, pneumobilia and an atypical mineral shadow on radiographs of the abdomen. The presence of two of these radiological signs has been considered pathognomic of gallstone ileus and is encountered in 40-50% of the cases (note than pneumobilia is common following endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy). At laparotomy, the stone is milked proximally away from the site of impaction. It may be possible to crush the stone within the bowel lumen; if not, the intestine is opened at this point and the gallstone removed. If the gallstone is faceted, a careful check for other enteric stones should be made. The region of the gall bladder should not be explored.
Gastrointestinal and Genitourinary Imaging
Published in Gareth Lewis, Hiten Patel, Sachin Modi, Shahid Hussain, On Call Radiology, 2015
Gareth Lewis, Hiten Patel, Sachin Modi, Shahid Hussain
The classic findings on an abdominal radiograph are of SBO (dilated loops of small bowel >2.5 cm), gas within the biliary tree (linear branching lucencies projected over the right upper quadrant) and a gallstone (usually in the right iliac fossa) (Figure 2.31). This is known as Rigler’s triad.
Bouveret syndrome as a rare cause of gastric outlet obstruction
Published in Baylor University Medical Center Proceedings, 2020
Pujitha Kudaravalli, Sheikh A. Saleem, Alexandra Goodman, Venkata Satish Pendela, Muhammad Osman Arif
Timely diagnosis of Bouveret syndrome is challenging, as the symptoms are nonspecific, leading to a mortality as high as 33%.4 Radiographs of the abdomen can show a dilated stomach, pneumobilia, and radiopaque shadow, which constitute the Rigler’s triad suggestive of Bouveret syndrome.6 Historically, endoscopy was used for the diagnosis of Bouveret syndrome. With advancements, CT is now the imaging modality of choice, with a sensitivity of 93% and a specificity of 100%. It better enhances and identifies the Rigler’s triad in addition to identifying the size and number of stones and the presence of a fistula and abscess. Oral contrast is used to enhance the appearance of the stone and for better visualization. If oral contrast is contraindicated, magnetic resonance cholangiopancreatography is the imaging modality of choice.4,6
Developments in the Diagnosis and Management of Cholecystoenteric Fistula
Published in Journal of Investigative Surgery, 2022
Ying-Yu Liu, Shi-Yuan Bi, Quan-Run He, Ying Fan, Shuo-Dong Wu
The sensitivity and specificity of computer tomography (CT) in the diagnosis of gallstone ileus were 93% and 100%. The CT findings of gallstone ileus are aeration in the gallbladder cavity, irregular gallbladder wall, and unusual gallstone location. Abdominal imaging showing pneumobilia, gallstones outside the gallbladder, and dilatation of the bowel are highly suggestive of gallstone ileus. These symptoms are known as the Rigler triad, however, the triad is only seen in 15% of cases [6, 17, 18]. Magnetic resonance cholangiopancreatography (MRCP) has unique advantages in displaying the anatomy of the biliary tree and is often used to suggest the location of CEF in the diagnosis of gallstone ileus. When CT is definitive, no additional imaging is required.
Rare cause of gastric outlet obstruction
Published in Journal of Community Hospital Internal Medicine Perspectives, 2018
Diagnosis depends on high index of clinical suspicion along with imaging studies [15]. The gold standard diagnostic test is EGD although CT scan, abdominal ultrasound and plain x-ray can be very helpful. Rigler’s triad of pneumobilia, an ectopic gallstone, and dilated small bowel on abdominal x-ray is classic but is only seen in 30%–35% of cases [6]. Classic CT scan findings are pneumobilia, cholecystoduodenal fistula and a gallstone in the duodenum [2,3,15]. Although, 15%–25% of gallstones cannot be visualized on CT scan as they can be isoattenuating. In those cases MRCP can help with diagnosis. EGD can be both diagnostic and therapeutic but success rate for stone removal is low.