Imaging Case of the Week 174 Answer

The abdominal x-rays show dilated small bowel loops with air fluid levels. The erect abdominal x-ray, on close examination shows air in the biliary tree. There are multiple rounded irregular densities in the mid abdomen (turned out to be calcified mesenteric lymph nodes on CT). This patient likely has a small bowel obstruction secondary to gall stone.

Small bowel dilatation


This patient went onto have a CT scan of the abdomen which confirmed gall stone related small bowel obstruction.

CT gall stone

CT pneumobilia

This patient had a 4 cm gall stone that had eroded the gall bladder causing a cholecysto-duodenal fistula and had lodged in the distal ileum causing small bowel obstruction.

Rigler’s triad consists of

  • Small bowel obstruction
  • Pneumobilia
  • Calcified gall stone in an ectopic location in the small bowel