2.  40 year old African T: 98.6 P 90 R 18 BP: 120/90
American female presents Gen: Normal appearing
female, NAD
to emergency department
HEENT: PERRL, oropharynx
complaining of abdominal clear, NC/AT head
pain, nausea/vomiting, an CV: RRR, no m/r/g
d constipation. She notes Pulm: CTAB
that she has had Abd: mildly distended,
occassional bouts of negative Murphy’s sign, mildly
TTP in RUQ, high pitched
colicky RUQ abdominal bowel sounds
pain for past few weeks and Ext: 2+ pulses, no c/c/e
has a history of gallstones.

4. Gallstone Ileus
•Rigler’s Triad:
•Pneumobilia
•SBO
•Impacted Gallstone
Gallstone Ileus
- Small bowel obstruction due to
passage of large gallstone, usually
through cholecystenteric fistula.
- Gallstone erodes through
gallbladder and into small
intestine.

5. •Pneumobilia
•Air in biliary tree
•Centrally located in liver

6. Portal Venous Gas
• More peripherally located
• Patients are usually ill-appearing
• Etiology: Ischemic Bowel, Necrotic Colorectal CA, NEC, IBD,
Appendicitis, Bowel Obstruction, Cholecystitis/Cholangitis,
Pancreatitis, Endoscopy

7.  Recent Instrumentation
 ERCP
 Incompetent Sphincter of Oddi
 Sphincterotomy
 Recent Passage of Gallstone
 Scarring from Chronic Pancreatitis
 Spontaneous Biliary-Enteric Fistula
 Gallstone Ileus
 Peptic Ulcer Disease
 Neoplasm (Cholangiocarcinoma, Ampullary Carcinoma)
 Trauma
 Biliary Enteric Surgical Anastomosis
 Whipple Procedure, etc
 Infection
 Emphysematous Cholecystitis
 Liver Abscess

8.  IV Fluid Resuscitation
 NPO
 Broad Spectrum Antibiotics
 Surgical Consultation/Admission
 Enterolithotomy
 Cholecystectomy may be delayed based on patient’s
comorbidities

9.  Saber Sign:
• supine radiographs; sword-shaped lucency in Right
paraspinal region, representing gas from common bile
duct and Left hepatic duct
• 50% of patients with pneumobilia.

10.  Harrison’s: Principles of Medicine, 17th Ed. Chapter 305
 http://www.learningradiology.com/archives05/COW%
20150-Gallstone%20Ileus/gallstoneileuscorrect.htm
 Schwartz, David. Emergency Radiology. 2000.
 Tintanelli’s Emergency Medicine: A Comprehensive
Study Guide.