AXR Quiz 1


An 81 year old woman presents with recurrent vomiting and abdominal pain. She is febrile and dehydrated.

What does the abdominal Xray show?

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There are three major findings on the supine film displayed. 

  1. There is evidence of a small bowel obstruction
  2. There is air in the biliary system (pneumobilia)
  3. There is a spherical, partly calcified mass in the right iliac fossa, consistent with an ectopic gallstone

Click to enlarge

This is known as Rigler's Triad [1], and represents Gallstone Ileus.  A CT is required to confirm these findings prior to laparotomy.

Gallstone Ileus arises when a fistula between a chronically inflamed gall bladder and the adjacent bowel develops, allowing the passage of a large gallstone into the bowel.  Direct communication between the biliary tract and the bowel allows air to enter, resulting in pneumobilia.  The stone often impacts at the level of the ileum, causing obstruction.  It is not uncommon for the obstruction to be intermittent as the stone progresses through the gastrointestinal tract before finally becoming stuck.

Gallstone Ileus is a relatively uncommon cause of mechanical bowel obstruction [2]. 

Calcification in the pelvis is likely to represent calcified uterine fibroids.


  1. Gallstone ileus with multiple stones: Where Rigler triad meets Bouveret's syndrome.  Gaduputi V, Tariq H, Rahnemai-Azar AA, Dev A, Farkas DT.  World J Gastrointest Surg. 2015;7(12):394. 

  2. Surgery for gallstone ileus: a nationwide comparison of trends and outcomes.  Halabi WJ, Kang CY, Ketana N, Lafaro KJ, Nguyen VQ, Stamos MJ, Imagawa DK, Demirjian AN.  Ann Surg. 2014 Feb;259(2):329-35. 

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Past Quizzes

Chest Xrays

Quiz 1 - Chest trauma

Quiz 2 - Fall from a bike

Quiz 3 - Hypoxia after intubation



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