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Whether got this fetail or notPatient Details Qlty: Rotation None Qlty: Inclusion (Diaphr to PS) Qlty: Position (Erect/Supine) Qlty: Exposure (adequate) Read: Air (free) Read: Bowel (dilated) Read: Small bowel dilated Read: Large bowel dilated Read: Calcifications Read: Dense Organs visible Read: Extraperitoneal fat planes seen Read: Foreign bodies seen Read: Girdle (bones normal) Diagnosis and management
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Reading File
Here is the complete structured radiological report and management plan for X-ray C:
Plain Abdominal X-ray (Supine) - Structured Report
QUALITY ASSESSMENT
| Parameter | Finding |
|---|---|
| Rotation | None - spinous processes midline, symmetrical |
| Inclusion (Diaphragm to PS) | Adequate - both domes of diaphragm to pubic symphysis included |
| Position | Supine (AP view) |
| Exposure | Adequate - vertebral bodies and soft tissue outlines visible |
SYSTEMATIC READING
| Feature | Finding |
|---|---|
| Air (free) | No pneumoperitoneum. No Rigler's sign (double-wall sign) or subphrenic free air |
| Bowel dilated | YES - multiple dilated loops visible |
| Small bowel dilated | YES - multiple central and left-sided loops of dilated small bowel (valvulae conniventes crossing full width), consistent with obstruction |
| Large bowel dilated | Minimal/absent colonic gas - expected in distal SBO |
| Calcifications | Faint oval calcified density in the right lower quadrant (arrowed) - ectopic gallstone |
| Dense organs visible | Liver and splenic shadows grossly normal. Branching linear gas lucencies in right upper quadrant over the liver shadow = PNEUMOBILIA |
| Extraperitoneal fat planes seen | Psoas shadows partially visualized bilaterally, roughly symmetrical |
| Foreign bodies | No metallic foreign bodies |
| Girdle (bones normal) | Lumbar spine shows mild degenerative changes. Pelvis, hip joints, lower ribs intact - no acute fractures |
DIAGNOSIS
GALLSTONE ILEUS
This X-ray demonstrates Rigler's Triad - the classic plain film triad diagnostic of gallstone ileus:
- Pneumobilia - branching gas lucencies in the biliary tree (right upper quadrant), caused by a cholecystoenteric (usually cholecystoduodenal) fistula
- Small bowel obstruction - multiple dilated central small bowel loops with a paucity of large bowel gas
- Ectopic gallstone - the white arrow points to a faintly calcified oval density in the right iliac fossa (likely impacted at the terminal ileum/ileocecal valve, the narrowest part of the small bowel)
Pathophysiology: A large gallstone (>2.5 cm) erodes through the gallbladder wall into the duodenum (cholecystoduodenal fistula), travels through the small bowel, and impacts at the narrowest point - the terminal ileum (~60% of cases), causing mechanical obstruction.
MANAGEMENT
Immediate / Resuscitation
- IV access, fluid resuscitation (correct dehydration and electrolyte imbalance - these patients are often elderly and unwell)
- NBM (nil by mouth)
- Nasogastric tube insertion and drainage
- Urinary catheter + strict fluid balance
- IV antibiotics (broad-spectrum - due to biliary sepsis risk)
- Bloods: FBC, U&E, LFTs, amylase, coagulation, group & save
- CT abdomen/pelvis (confirms diagnosis, localizes stone, identifies additional stones, delineates fistula)
Surgical Management
- Definitive treatment: Exploratory laparotomy
- Enterolithotomy - longitudinal enterotomy proximal to the obstruction, stone extraction, then transverse closure
- Milk any other stones proximally to prevent recurrence
- Decision regarding cholecystectomy + fistula repair at the same sitting vs. interval procedure:
- Most surgeons prefer enterolithotomy alone first (especially in high-risk, elderly patients) due to the complexity and morbidity of one-stage repair
- Interval cholecystectomy can be performed electively if the fistula does not close spontaneously (only ~10-15% require it)
Post-operative Care
- HDU/ICU monitoring
- DVT prophylaxis
- Nutritional support
Key teaching point: This is a condition of elderly women (F:M = 3.5:1), typically >65 years, with a history of gallstones. Mortality is 15-18% due to the age and comorbidity of the patient population. Only ~14% of ectopic gallstones are radio-opaque, making the pneumobilia and SBO pattern the more reliable diagnostic clues on plain film.
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