A30) Abdominal pain and distension

Review the Learning Outcomes, Hx, PE and Labs, and begin the module with your Provisional Diagnosis. Keep hitting "Next" to move through the module.

Learning Outcomes

  1. Identify the role of consulting diagnostic radiologists in evaluating a patient with abdominal pain.
  2. Generate a list of possible diagnoses for a patient with lower abdominal pain based on their symptoms and medical history.
  3. Analyze the appropriate imaging modalities and spectrum of imaging findings for evaluating a patient with abdominal pain.


Physical Exam


Provisional Diagnosis

Select the Dx you believe is most appropriate
Given the patient's history of nausea, vomiting, constipation, and abdominal distention, small bowel obstruction is the most appropriate provisional diagnosis. The elevated creatinine and BUN/creatinine ratio suggests hypovolemia from dehydration.
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Potential Acuity

What is your assessment of the likely acuity for this patient?

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The patient requires urgent workup and management.

First Imaging Study

What is the first imaging study you will order?

A CT of the abdomen and pelvis is a fast and non-invasive imaging technique that can efficiently assess the presence of a small bowel obstruction, its etiology, and any accompanying complications.
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Pertinent Imaging Observations

Click on the links below to view images from the study, and assess these key findings as best you can.

Watch our video

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Second Imaging Study

What is the next imaging study you will order?

None, the diagnosis of small bowel obstruction secondary to an obstructing gallstone has been confirmed by CT.
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What is your Diagnosis now that you have seen the imaging results?

The imaging findings are consistent with all the above diagnoses.

Current Acuity

Initially, you selected and we suggested acuity.

Has your concern for this patient changed?

The patient requires urgent workup and management.

Assessment and Plan

Please provide your assessment and plan for this patient

The patient, a 75-year-old female with a history of cholelithiasis, presents with symptoms consistent with gallstone ileus. CT imaging confirms a small bowel obstruction caused by a gallstone in the small bowel with pneumobilia secondary to a cholecystoduodenal fistula. General surgery should be consulted for evaluation and management. Treatment options include surgical enterolithotomy and possible cholecystectomy with biliary-enteric fistula closure. In the interim, the patient should be made NPO, started on IV fluids, and undergo nasogastric decompression.

Lessons Learned:
- Gallstone ileus is a rare but serious condition that can cause mechanical bowel obstruction.
- Symptoms of small bowel obstruction include nausea, vomiting, abdominal pain, abdominal distension, and obstipation. These symptoms can be vague and nonspecific, so a high degree of clinical suspicion is necessary to make the diagnosis.
- CT imaging is an important diagnostic tool for gallstone ileus, and can reveal the presence of a gallstone in the small bowel, pneumobilia, a small bowel obstruction (Rigler’s triad), and a cholecystoduodenal fistula.
- Similarly, if an X-ray was obtained, it can reveal a gallstone, pneumobilia, and small bowel obstruction.
- Risk factors for gallstone ileus include elderly age, chronic cholecystitis, and a history of gallstones larger than 2cm.
- Surgical enterolithotomy is the first-line treatment for gallstone ileus, and generally involves the removal of the obstructing gallstone through an enterotomy, cholecystectomy, and closure of the biliary-enteric fistula.

Socioeconomic Factors: Careful post-operative follow-up is important for all patients undergoing surgery for small bowel obstruction, but it is especially important for Medicare and Medicaid patients who may have higher readmission rates.

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