Endgames Spot Diagnosis

Losing a marble

BMJ 2016; 354 doi: https://doi.org/10.1136/bmj.i4486 (Published 26 August 2016) Cite this as: BMJ 2016;354:i4486
  1. Adrian Iordache, foundation year 2 house officer1,
  2. Paul Young, foundation year 1 house officer1
  1. 1James Cook University Hospital, Middlesbrough, UK
  2. Correspondence to: adrian.iordache{at}nhs.net

A 44 year old woman with no medical history presented with abdominal pain, vomiting, and lack of bowel movement for four days. Apart from an increased bilirubin level (32 μmol/L, range: <21 μmol/L) blood markers were unremarkable. What is the eponymous radiological finding and diagnosis in this plain abdominal radiograph (fig 1)?


Rigler’s triad, pathognomic of gallstone ileus.


Gallstone ileus occurs in less than 0.5% of patients with cholelithiasis.1 Patients with gallstone ileus usually have had previous episodes of cholecystitis. Inflammation causes adhesions with adjacent structures (usually duodenum) and may permit a gallstone to erode the wall and travel into the bowel via a fistula.

Most ectopic gallstones transit through the bowel and are spontaneously passed via the rectum. Sometimes they may impact and obstruct the bowel, leading to gallstone ileus. The most common site of obstruction is the terminal ileum at the ileocaecal valve (B) (fig 2). Rarely, a stone may impact in the proximal duodenum, causing a gastric outlet obstruction known as Bouveret’s syndrome.2


Fig 2 Plain abdominal radiograph showing pneumobilia (A), ectopic gallstone in right iliac fossa (B), and distended small bowel loops (C) suggestive of obstruction

Rigler’s triad is present in just 15% of cases. Pneumobilia (A), ectopic gallstone (B), and distended small bowel loops (C) suggestive of obstruction are the classic radiological findings in gallstone ileus (fig 2). At laparotomy, a 5 cm gallstone was extracted from the terminal ileum through an enterotomy. The patient made a good postoperative recovery and was discharged after six days.


  • Competing interests: We have read and understood the BMJ policy on declaration of interests and declare the following: none.

  • Provenance and peer review: Not commissioned; externally peer reviewed.

  • Patient consent: Obtained.


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