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Small Bowel Obstruction Secondary to Gallstone Ileus with Finding of Rigler’S Triad on CT Abdomen: a Case Report

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Small Bowel Obstruction Secondary to Gallstone Ileus with Finding of Rigler’S Triad on CT Abdomen: a Case Report Case Report Clinics in Surgery Published: 09 Feb, 2017 Small Bowel Obstruction Secondary to Gallstone Ileus with Finding of Rigler’s Triad on CT Abdomen: A Case Report Raniga H, Shekhar A and Hendehewa R* Department of Surgery, Caboolture Hospital, Australia Abstract Gallstone ileus is an infrequent cause of small bowel obstruction. It mainly affects the elderly population with a female predominance. Many individuals often have concurrent history of chronic cholelithiasis. A fistula between the gallbladder and duodenum allow for the passage of a gallstone into the small bowel potentially leading to mechanical obstruction. Diagnosis can be difficult even with the help of modern imaging modalities which can lead to a delay in management and high risk of morbidity and mortality. This case demonstrates a commonly cited sign of gallstone ileus known as Rigler’s Triad; small bowel obstruction, a gallstone outside the gallbladder, and air in the biliary tree. Introduction Small bowel obstruction is a serious condition which has the potential to become a surgical emergency if left untreated. The most common causes of small bowel obstruction in adults include adhesions, hernias and tumour [1]. However, rarer causes of mechanical bowel obstruction should be considered if a diagnosis is uncertain. Gallstone ileus is an important but rare cause of small bowel obstruction accounting for about 1-4% of cases of intestinal obstruction [2]. The intermittent and variable symptomatology of gallstone ileus may potentially delay diagnosis which may be a contributing factor that accounts to its relatively high rate of associated morbidity and mortality. In this case, we describe a case of acute small bowel obstruction in a 58-year-old lady secondary to an impacted gallstone at the terminal ileum. She went on to receive an open laparotomy. Case Presentation OPEN ACCESS Background *Correspondence: Rasika Hendahewa, Department of A generally healthy 58 year old lady presented to the emergency department from the GP with a 3 day history of cramping central abdominal pain with associated nausea and vomiting. She has also Surgery, Caboolture Hospital, 120 noted a 1 month history of abdominal pain after eating high fat meals. McKean Street Caboolture QLD 4510, Australia, Preoperative assessment E-mail: [email protected]. On clinical examination, the abdomen was soft with some periumbilical tenderness. Routine gov.au blood test was significant for left shifted leukocystosis. An abdominal CT scan requested by the GP Received Date: 21 Nov 2016 earlier in the day demonstrated what initially looked to be a central small bowel necrotic mass with Accepted Date: 23 Jan 2017 distal small bowel obstruction and transition point at the terminal ileum (Figure 1). On further Published Date: 09 Feb 2017 evaluation of the CT abdomen, free air was noted in the biliary tree (Figure 2). These findings are Citation: classically sited as Rigler’s Triad; small bowel obstruction, pneumobilia, and gallstone outside the Raniga H, Shekhar A, Hendehewa R. gallbladder. Small Bowel Obstruction Secondary to Operative technique Gallstone Ileus with Finding of Rigler’s She subsequently went on to receive an urgent laparoscopy which was converted to open Triad on CT Abdomen: A Case Report. laparotomy in view of suspicious CT scan findings. A midline incision was done with careful Clin Surg. 2017; 2: 1294. exploration of the small bowel. A large 4 cm palpable gallstone was found in the terminal ileum Copyright © 2017 Hendehewa R. This (Figure 3). A wedge resection was carried out to remove the gallstone (Figure 4). Cholecystectomy is an open access article distributed and fistula closure was delayed in this case in view of the clinical situation. She will receive an MRCP under the Creative Commons Attribution at a later date before any subsequent procedure. The patient remained in hospital post surgery and License, which permits unrestricted was discharged on post-operative day 5 without complication. use, distribution, and reproduction in Discussion any medium, provided the original work Gallstone disease is a common condition which usually presents with a history of biliary colic. is properly cited. Remedy Publications LLC., | http://clinicsinsurgery.com/ 1 2017 | Volume 2 | Article 1294 Hendehewa R, et al., Clinics in Surgery - General Surgery Figure 4: 4 cm gallstone excised during enter olithotomy. Figure 1: CT Abdomen demonstrating dilated loops of bowel. Arrow indicating site of suspected gallstone obstruction. often leads to a delay in preoperative diagnosis and higher rate of morbidity and mortality. Consideration should be made in any elderly female patient presenting with symptoms of small bowel obstruction with a previous history of cholelithiasis or cholecystitis. On abdominal plain film, Rigler’s triad is often sited: pneumobilia (air in the biliary tree), signs of small bowel obstruction, and radio-opaque gallstone on imaging. An abdominal CT was done in this case which demonstrated signs of small bowel obstruction and what looked like a necrotic mass rather than a radio-opaque stone. It should be noted that a preoperative diagnosis is only made in about 50-60% of cases and findings demonstrating Rigler’s Triad are generally rare. As a result, definitive diagnosis is often delayed until laparotomy. Treatment options largely depend on a patient’s clinical status. Figure 2: CT Abdomen demonstrating with arrow demonstrating pneumobilia or air in the biliary tree. The most common surgical approach to managing gallstone ileus is an enterotomy with stone retrieval which was done in this case. In terms of managing the gallbladder and fistula, there is controversy as to whether a delayed fistula closure versus a single stage procedure comprised of enter olithotomy, cholecystectomy and fistula closure is of benefit. In up to 50% of cases, a fistula may spontaneously close [5]. In addition, the rate of gallstone ileus recurrence is generally low (5-9%) following enter olithotomy. Learning Points 1. In elderly females with history of cholelithiasis and biliary colic presenting with nausea, vomiting and signs of small bowel Figure 3: Laparotomy with enter lithotomy near the terminal ileum. obstruction; gallstone ileus must be considered as early surgical management is critical. In the majority of cases, gallstone disease may be complicated by acute cholecystitis, gallstone pancreatitis, or choledocholithiasis. 2. Although CT scan is helpful, preoperative diagnosis is However, in about 0.5% of patients with gallstone disease, gallstone often delayed until laparotomy and Rigler’s Triad is not commonly ileus may occur; a relatively rare cause of small bowel obstruction [3]. demonstrated on imaging. Our patient was a relatively elderly lady that demonstrated about a 3. Although controversy exists, Enter olithotomy with delayed 1-month history of biliary colic prior to presenting. This prompted cholecystectomy and fistula closure remains an acceptable surgical gallstone ileus as a possible differential. option in the management of gallstone ileus. Gallstone ileus occurs most often in elderly individuals. References Approximately 70% of patients are over the age of 65. Females are three and a half times more likely than males [4]. 1. Christopher. Abdominal X-rays for Medical Students. John Wiley & Sons. 2015; 33. Fistula formation between the gallbladder and duodenum is the 2. Konstantinidis C, Hamzin A, Stefanidis I. Gallstone Ileus-A Case Report most common explanation for gallstone ileus. A fistula may allow with Review of the Literature. AJMCR. 2015; 3: 126-129. passage of a stone into the small bowel. Small bowel obstructions generally occur with stones >2.5 cm in size [4]. Impaction of the stone 3. Mohamed A, Bhat N. Gall Stone Ileus. A Rare Complication of Gallstone most commonly occurs near the ileocaecal valve due to a narrow Disease. Case Report and Literature Review. Int J Surg. 2008; 21. lumen with less frequent peristaltic activity. In this case, the gallstone 4. Farook S, Harrion J. Recurrent Gallstone Ileus, Case Report and Literature was approximately 4 cm in size and was located in its classic position Review. J Abdominal Surg. 2010. near the terminal ileum. 5. Dai X, Li G, Zhang F, Wang X, Zhang C. Gallstone ileus: Case report and The clinical symptoms of gallstone ileus are non-specific which literature review. World J Gastroenterol. 2013; 19: 5586-5589. Remedy Publications LLC., | http://clinicsinsurgery.com/ 2 2017 | Volume 2 | Article 1294.
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