Rigler's triad in an 88-year-old woman.

An 88-year old woman was seen at the emergency department with sudden onset of abdominal pain and nausea. She had been constipated for a week. Medical history was positive for arterial hypertension, diabetes mellitus type II, and heart failure. Laboratory findings showed an elevation of cholestatic liver enzymes. CRP was within normal limits. An upright radiograph of the abdomen showed multiple air fluid levels in the small bowel consistent with obstruction. Pneumobilia was also seen as well as an obstructing gallstone. A CT of the abdomen was performed. This showed pneumobilia, a small bowel faeces sign in the jejenum consistent with obstruction, and a non radioopaque gallstone in the ileum. A CT scan from a few years earlier shows signs of cholecystitis and the non radioopaque gall stone. The patient was treated with laparascopic enterotomy with removal of the gallstone and cholecystectomy. The cholecystoduodenal fistula was demonstrated.