Gallstone ileus with Rigler’s triad in a 68-year-old male: An uncommon cause of intestinal obstruction

Abstract

Gallstone ileus is a rare cause of mechanical bowel obstruction resulting from a gallstone migrating into the gastrointestinal tract through a biliodigestive fistula. It mostcommonly affects the distal ileum and is more prevalent in elderly patients. We present the case of a 68-year-old male with a history of hypertension who was admitted with vomiting and abdominal distension for 72 hours. CT imaging revealed pneumobilia, intestinal obstruction, and an ectopic gallstone, consistent with Rigler’s triad. The gallstone, measuring 3 × 2 cm, was located 130 cm distal to the Treitz ligament. The patient underwent an emergency exploratory laparotomy with enterolithotomy, successfully removing the gallstone. Postoperatively, the patient recovered uneventfully, with complete resolution of symptoms. Gallstone ileus should be considered in elderly patients with intestinal obstruction, and early diagnosis using CT imaging is crucial for guiding treatment. Enterolithotomy remains the preferred surgical intervention with favorable outcomes in most cases

Introduction

Gallstone ileus represents an intestinal obstruction that results from the migration of a gallstone into the intestinal lumen via a biliodigestive fistula, most commonly situated between the duodenum and the gallbladder. This condition is considered a rare cause of intestinal obstruction, accounting for approximately 1% of all cases of mechanical intestinal obstruction, with the distal ileum being the most frequently affected site [1,3].

The prevalence of this condition increases among individuals over the age of 60, with an average presentation age of 74 years. Such patients are often frail and possess multiple comorbidities [2]. Due to the advanced age of the affected population, coupled with delayed diagnosis and treatment, gallstone ileus has a reported mortality rate ranging from 12% to 27% and a morbidity rate of 50%. Individuals diagnosed with gallstone ileus frequently exhibit a history of cholelithiasis, advanced age, acute episodes of cholecystitis, and gallstones exceeding 2 cm in size [2,3]. Furthermore, gallstone ileus is more prevalent in women than in men, with a female-to-male ratio ranging from 3:1 to 7:1 [3].

Rigler’s triad is regarded as a pathognomonic radiological finding indicative of gallstone ileus. This triad includes pneumobilia, intestinal obstruction, and an ectopic gallstone located within the intestine. While this triad is not routinely identified through plain radiography or ultrasound, it is more commonly observed utilizing computed tomography (CT) [3,4].

In this document, we present the case of a 68-year-old male patient diagnosed with gallstone ileus and intestinal obstruction. Radiological studies, including CT imaging, successfully identified the pathognomonic Rigler’s triad. The patient subsequently underwent surgical intervention, specifically an exploratory laparotomy with enterolithotomy.

Case report

A 68-year-old male patient with a ten-year history of arterial hypertension was admitted to the emergency department of our institution due to recurrent vomiting and the absence of gas passage for seventy-two hours preceding admission. Upon clinical examination, oral mucosal dehydration and marked abdominal distension with reduced peristalsis were observed. Laboratory studies revealed leukocytosis (20,000), predominantly due to polymorphonuclear cells, in conjunction with hypochloremia.

An abdominal X-ray in 2 views indicated signs of mechanical obstruction, highlighting intestinal loop dilation. A computed tomography (CT) scan confirmed significant abdominal distension, pneumobilia, and an ectopic gallstone located in the intestine, identified as the etiology of the intestinal obstruction and the patient's symptoms. The CT findings were consistent with Rigler’s radiological triad: pneumobilia, intestinal gas, and an ectopic gallstone (Fig. 1, Fig. 2). Based on these findings, a diagnosis of gallstone ileus was established.

Fig. 1.

CT scan in the coronal plane of the abdomen showing pneumobilia (white arrow) and air-fluid levels within dilated intestinal loops (red arrow), findings consistent with mechanical bowel obstruction.

Fig. 2.

CT scan in axial view of the abdomen demonstrates the presence of an ectopic gallstone (red arrow) and a distension of small Bowe (white arrow).

The patient underwent an emergency exploratory laparotomy. Intraoperatively, markedly dilated small bowel loops were identified (Fig. 3), consistent with mechanical obstruction. A clearly distended intestinal segment is demonstrated in the intraoperative image. A longitudinal enterotomy was performed to extract the obstructing gallstone, which measured 3 × 2 cm and was located approximately 130 cm distal to the ligament of Treitz (Fig. 4). The stone was successfully removed without complications.

Fig. 3.

Intraoperative image showing the clearly distended intestine (red arrow), indicating changes associated with intestinal obstruction.

Fig. 4.

Gross specimen of the impacted gallstone, measuring 3 × 2 cm.

The postoperative recovery was uneventful, and the patient demonstrated a favorable clinical evolution, with complete resolution of symptoms.

Discussion

Gallstone ileus is a mechanical bowel obstruction caused by the migration of a gallstone into the intestinal lumen through a biliodigestive fistula. This condition represents a rare and delayed complication of untreated cholecystitis [1].

The incidence of gallstone ileus has remained consistent at approximately 30-35 cases per million hospital admissions over the past 45 years. It affects 0.3%-0.5% of individuals with cholelithiasis and constitutes less than 5% of all intestinal obstructions. This condition predominantly occurs in older individuals, with the most commonly affected age group being 60-84 years. Reflecting the higher prevalence of gallstones in women, gallstone ileus is more frequently observed in females, with incidence rates ranging from 72% to 90% [5]. Although infrequent, involvement of male patients has also been documented in the literature, as observed in our case [[6], [7], [8], [9], [10]].

The obstruction results from the impaction of gallstones, typically measuring over 2-2.5 cm in diameter, within the gastrointestinal tract. While smaller stones may pass uneventfully, they can aggregate and form obstructive masses. The most frequent sites of impaction include the terminal ileum and ileocecal valve, accounting for 60% of cases, followed by the jejunum (16%), stomach (15%), and colon (2%-8%). The formation of bilioenteric fistulas, predominantly cholecysto-duodenal fistulas, facilitates the migration of gallstones into the bowel. These fistulas develop due to chronic inflammation or erosion. Larger stones, particularly those exceeding 5 cm, are more likely to cause obstruction, leading to severe complications such as ischemia, necrosis, or perforation if not promptly managed [5,11].

Computed tomography (CT) is the diagnostic modality of choice for gallstone ileus, offering superior anatomical detail and high sensitivity in identifying critical features such as bowel obstruction (96.3%), ectopic gallstones (81.48% to 92%), and Rigler’s triad (77.78%). Rigler’s triad is pathognomonic for gallstone ileus, but in most cases, only 2 signs out of the triad are present. In the literature, only 14%-53% of cases present with the full criteria. Compared to abdominal X-rays (AXR) and ultrasound, CT demonstrates markedly greater diagnostic accuracy, underscoring its indispensable role in confirming the diagnosis and guiding treatment strategies [11].

Enterotomy with stone extraction alone (ES) is the preferred surgical approach for gallstone ileus, with the lowest in-hospital mortality rate (4.89%) and reduced postoperative complications compared to more invasive procedures. Bowel resection (BR) and enterotomy with fistula closure (EF) have significantly higher mortality rates, at 12.87% and 7.32%, respectively, and are associated with increased risks of complications like acute renal failure (38.61% for BR) and anastomotic leaks (18.81% for EF). ES also results in shorter hospital stays and lower costs, making it the most suitable initial treatment. Although one-stage procedures like EF may address long-term risks, such as recurrence or gallbladder cancer, they are best reserved for healthier patients due to their higher complexity and risk. Elective fistula closure after initial ES offers favorable outcomes with minimal mortality (2.94%), further supporting ES as the optimal acute intervention [12].

Conclusion

Biliary ileus is a rare and potentially life-threatening condition that requires early diagnosis and urgent surgical intervention. Rigler’s triad, a pathognomonic radiological finding, is crucial for facilitating early disease identification, enabling timely treatment. Enterolithotomy is the preferred surgical approach, as it significantly reduces morbidity and mortality, particularly in patients with severe comorbidities. Therefore, early intervention should be prioritized, and advanced imaging techniques, such as computed tomography (CT), should be utilized to ensure an accurate diagnosis and optimize outcomes in these cases.

Patient consent

Informed consent was obtained from the patient.