Rigler triad
Gallstone ileus occurs when a gallstone enters the small bowel via a biliary-enteric fistula, causing a mechanical bowel obstruction. It is more common in elderly populations with a higher incidence in women.
Description
Leo George Rigler (1896-1979) defined the Rigler triad for plain imaging findings in patients with gallstone ileus:
- an ectopic gallstone causing
- partial or complete small bowel obstruction, and
- pneumobilia and/or gallbladder lumen gas
Rigler triad: 1. pneumobilia; 2. small bowel obstruction; 3. ectopic calcified gallstone
Case courtesy of Assoc Prof Frank Gaillard. Case rID: 6906
History of the Rigler triad
1941 – Leo George Rigler (1896-1979) described two cases, observed at autopsy, in which the manner of development of a choledochoduodenal and a cholecystoduodenal fistula could be demonstrated.
The specific signs which permit a roentgenologic diagnosis of this condition are evidences of dynamic ileus, presence of gas or contrast medium in the biliary tract and direct or indirect visualization of the calculus.
In 13 of 14 cases of gallstone obstruction in which roentgen examination was made, the exact diagnosis could have been made from the roentgenograms alone
Rigler, JAMA 1941
History of the gallstone ileus
1654 – The first case of cholecystointestinal fistula with probable entrance of a gallstone into the alimentary tract was recorded by Thomas Bartholin (1616-1680) in 1654 as Historia LIV. Novus bilis ductus & Pancreatitis tumor. He recorded the 1652 dissection of a female patient by German surgeon, and anatomist, Johannes Veslingius Mindanus [aka Johann Vesling (1598-1649)]
Original
English
Interim provida natura ad bilem expurgandum alium efformaverat ductnm ab hepate prodeuntem, poro bilario a calculis constipato vicinum, qui in jejunum intestinum terminabatur.
Meanwhile, provident nature had formed another duct for the purging of bile, coming from the liver, adjacent to the biliary pore clogged with stones, which terminated in the jejunum*.
**“Jejunum” probably “duodenum”, as in the past and up until the 1900’s there was often no strict distinction between the two sections of the intestine.
1890 – The first published article on this subject, by Ludwig Georg Courvoisier (1843-1918) with his collated 131 cases.
1896 – Léon Bouveret (1850-1929) defined Bouveret syndrome as a reverse gallstone ileus where the gallstone propagates proximally and causes gastric outlet obstruction by being impacted in first part of duodenum.
Obstructions of the gastro-intestinal tract by gallstones may be divided into two distinct epochs : First, that which preceded the appearance of the monograph of Courvoisier in 1890; and, second, the period from 1890 to 1910.
In the later years, surgery has been the dominant treatment of gallstone disease. Courvoisiers epoch-making article which included practically all recorded cases in the Christian era, gave a new impetus to surgical thought on the subject of cholelithiasis. His forceful presentation of the pathologic conditions of gallstones in the gall-bladder, cystic duct, common duct, intestine, peritoneal cavity, etc., showed that there was a great field for mechanical intervention in lesions resulting from cholelithiasis.
1914 – Van Wagner compiled 334 cases.
1925 – George Albert Moore estimated that about 400 cases had been reported
1942 – Foss and Summers collected an additional 150 cases
Associated Persons
- Leo George Rigler (1896-1979)
Alternative names
- Rigler’s triad
References
Historical references
- Rigler LG, Borman CN, Noble JF. Gallstone obstruction: pathogenesis and roentgen manifestations. JAMA. 1941; 117(21): 1753-1759
Rigler triad references term review
- Lassandro F, Romano S, Ragozzino A, Rossi G, Valente T, Ferrara I, Romano L, Grassi R. Role of helical CT in diagnosis of gallstone ileus and related conditions. AJR Am J Roentgenol. 2005 Nov;185(5):1159-65
- Rippy J. Ultrasound Case 032. LITFL
- Bickle I. Rigler triad (gallstone ileus). Radiopaedia
Gallstone ileus references
- Bartholinus T. Historia LIV. Novus bilis ductus & Pancreatitis tumor. Historiarum anatomicarum rariorum centuria I et II. 1654
- Bouveret L. Sténose du pylore adhérent à la vésicule calculeuse, Revue de médecine, Paris 1896; 16: 1-16
- Courvoisier LG. Casuistisch-statistiche Beiträge zur Pathologie und Chirurgie der Gallenwege. 1890
- Murphy JB. Gallstone disease and its relation to intestinal obstruction. Illinois Medical Journal. 1910; 18: 272-280
- Martin F. Intestinal obstruction due to gall-stones: with report of three successful cases. Ann Surg. 1912;55:725–743.
- van Wagner A. Ileus durch Gallensteine. Deutsche Zeitschrift für chirurgie. 1914; 130: 353-388.
- Moore GA. Gallstone Ileus. The Boston medical and surgical journal. 1925; 192(22): 1051-1055.
- Foss HL, Summer JD. Intestinal Obstruction from Gallstones. Ann. Surg., 1942; 115: 721
- Deckoff SL. Gallstone ileus; a report of 12 cases. Ann Surg. 1955 Jul;142(1):52-65.
eponymictionary
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