Dr. Pepe’s Diploma Casebook: Case 4 – SOLVED!

Dear Friends,

Abdominal films are being displaced nowadays by CT and US; but they are still useful if interpreted properly. In this case you are provided with a supine film of an 84-year-old man who has experienced epigastric pain, vomiting and abdominal distension for several days.

Fig. 1

Possible diagnoses:

1. Pancreatitis
2. Pyloric obstruction
3. Perforated hollow viscus
4. None of the above

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    21 Responses to : Dr. Pepe’s Diploma Casebook: Case 4 – SOLVED!

    1. Guibernau says:

      -The presence of intraluminal air in colon (normal distributed) discard the pyloric obstruction and make me think that the gastric image is a kind of gastroparesia.
      -You can see well defined the ilio-psoas line so t seems no to be significant free fluid.
      -There’s no pneumoperitoneum suggestive of hollow viscus perforation
      -There’s a round density on right hypochondrium suggestive of colelitiasis. So in a patient with compatible symptoms it can be a biliar colic.
      Option 4, none of the above.

    2. Adrian says:

      There’s no pneumoperitoneum, so hollow viscus perforation it’s unlikely.
      Pyloric obstruction wouldn´t be my choice, because there’s distal air in small and large bowel, although it could be an incomplete obstruction.
      Pacient can have a pancreatitis, since it’a an analitic based diagnosis and Xray may be normal, but I don’t think it´s going to be the answer.
      Estomach is dilated, and so is a small bowell loop on right side, close to the round calcium density (it´s not projected on the gallbladder area) so I can´t rule out a biliary ileum.
      So I would choose no 4. None of the above.

    3. Jess says:

      Main findings on this plain abdominal radiograph:
      mineral density caudal to the right hypochondrium
      hint of biliary tree gas (central distribution – sparing periphery)
      dilated segment of small bowel and distended stomach (though history gives a more convincing obstructive picture than the imaging does!)

      Dr Pepe, I would really love to see this patient’s CT Scan!!!

      Pneumobilia + SBO + Visible stone = Rigler’s Triad in Gallstone Ileus

      My answer = 4 None of the above

    4. aca says:

      There is no normal gas bouble in fornix of the stomach,and fornix looks thickened,indicates Neo or hiatus haernia?
      There is a calcium stone shadowing in right subhepatic space,sugestive of bile stone…duoodenal loop is distended,sugest acute upper suboclusion or pancreatitis maybe

    5. mustafa says:

      -”There’s no pneumoperitoneum suggestive of hollow viscus perforation” ???
      It’s a supine film… I think ‘3’ is correct answer !

    6. p.s says:

      Gas within the urinary bladder wall…Rare condition found in diabetics…Emphysematous cystitis, I think…

    7. Genchi Bari Italia says:

      Ileo biliare, da “migrazione” di calcolo rx-opaco in sede ilieale.

    8. yasir says:

      Well, i think that there is a genelaized lucency in the abdomen suggestive of free air, and since this is a supine film we are not able to see the cupola sign of pneumoperitoneum. However again i must say that both the internal and external walls of stomach are very well visualized. I am not sure whether this is a case of Rigler or not but , 2) there is radioopaque calcific density in Right hypochondrium as well and 3) moreover there are distended small bowel loops too in the presence of which i ll be very concerned with this overall lucency strengthning my suspicion of free air. 4) i ll be very interested to see if there is pneumobilia now but truly speaking even if its there i m unable to pick it and its very subtle.
      I think this is a case of Gall stone ileus.
      so it perforated hollow viscus.

    9. yasir says:

      I hope Dr Pepe doesnt have any thing very rare here ! I ll be a bit surprised with that Dr Pepe !

    10. Mihai Comsa says:

      4. None of the above

      – gallstone ileus I think !


      non f the above
      i think of bowel ischemiaor mesentric ischemia there is sign dialated segment of small bowel

    12. Olgi says:

      Pyloric obstruction . Dilated stomach, no significant air in the small bowel , normal air content in the large intestine. Chololith – big one, usually with no clinical Importance.

      • Jose Caceres says:

        You are overlooking the dilated small bowel loop in the right flank. How do yo know that the so-called chololith is indeed a chololith?

    13. Genchi Bari Italia says:

      Chiarisco meglio quanto ho già detto : calcolo colecistico, in sede “anomala, ” circondato da gas che Non è nel lume intestinale, ma libero , per migrazione del calcolo nel piccolo intestino, con perforazione “coperta” dalla reazione mesenteriale che “blocca” le bolle d’aria in “vicinanza” dell’ansa in sofferenza, per probabile necrosi della parete.

    14. Albert says:

      Dilated stomach and small bowell loop in the right flank, dense subhepatic oval image and probable air bubbles suggestive of pneumobilia.
      I don’t clearly see an ileus, anyway can’t be sure with a supine projection (as far as I concern not useful projection to study occlusive episodes).
      I dont see a double wall sign to think of perforation.
      I would think of a biliary ileus or one of its variants: Bouveret Syndrome.

    15. vishal kalia says:

      The CT topogram of abdomen showing moderately dilated small bowel loop in right lumbar region with a lamellated calcified density. Some air locules are seen adjacent to it with a soft tissue opacity in right lumbar region likely displacing the gut. No free air is seen in the abdomen. The properitoneal fat lines ,psoas shadows and pelvic fat planes are maintained-suggesting abscence of free fluid. There is colon cut off in the proximal transverse colon.No air is seen in rest of the small bowel loops. Small amount of air is seen in the colon with normal haustral pattern. x-ray findings are suggestive of fecolith with SBO. I am not sure of air in the biliary channels.The common causes of fecoliths are GB stones, appendicoliths or secondary to some foreign body or bezoars. based on clinical findings, the possibility will be of cholecystitis with gall stone within GB and few air loculi-emphysematous/gall stone ileus(common cause of fecolith but the points against are -not a typical location for terminal ileum and male patient although the site could be explained by bouveret syndrome-still it is more lateral for duodenum ). It could be appendicolith with appendicitis/appendicular tumor in retrocaecal location with SBO and colon cut off-but points against are big calcified density-appendicoliths are usually small and and lack of any pain in the right iliac region). Other causes like foreign body or bezoar can be excluded from the history.

      • Dr. Pepe says:

        Good discussion, as always. Lack of pain in right iliac region does not exclude appendicitis in an 86 y.o. man. Clinical symptoms may be vague.

    16. aca says:

      dif.dg. maybe apendicolith or ureterolith vs. bile stone on the right?

      • Dr. Pepe says:

        I would say that it is too lateral to be in the urinary tract. Cannot exclude appendicolith; but it is too big (the mother of all apendicoliths!). Also, the air in right upper quadrant points to biliary ileus.