EMERGENCY IMAGING FINDINGS • SENIOR RESIDENT / SURGEON

Pneumobilia

Central biliary air is a finding, not a diagnosis: distinguish expected post-procedural air from gallstone ileus, infection, and fistula.

PROTOTYPE REVIEW REQUIRED

The Call

67-year-old woman with vomiting, distention and obstipation

Several days of obstructive symptoms with no prior abdominal surgery. Imaging shows pneumobilia and a distal small-bowel transition point.

HR 102 • BP 136/78

Pneumobilia plus mechanical SBO should immediately raise concern for gallstone ileus.

Read the Image • Clinical Data

Abdominal Film / CT Central branching biliary air, bowel obstruction and an ectopic gallstone form the classic imaging pattern. Clinical image slot reserved for this case.

Make the Decision • Commit to a Plan

Pneumobilia

67-year-old woman with vomiting, distention and obstipation

An elderly patient has SBO, ectopic calcified gallstone and pneumobilia. Best initial surgical target?

The stone is removed from distal ileum. The patient is frail and hypotensive; the cholecystoenteric fistula is densely inflamed. Best principle?

Postoperatively the patient has recurrent obstruction symptoms. Best next concern?

Relieve the obstruction and assess bowel viability.

Recovery depends on both obstruction relief and frailty.

Surgical Pearls

Pitfalls

CT shows pneumobilia, SBO, and a 3.5-cm ectopic stone in the distal ileum. What is the key immediate surgical goal?