0:00

Okay, here is another contrast-enhanced

0:03

CT scan of the abdomen and pelvis.

0:05

And as we come down, we're gonna see that

0:07

we have dilated loops of small bowel and

0:08

keeping with small bowel obstruction.

0:10

But let's go back up.

0:11

What have I taught you?

0:13

So we see air here within the

0:15

central aspect of the liver.

0:17

We have to decide, do we think this is biliary

0:19

air, or do we think that this is portal venous air?

0:22

So actually we can track this air all

0:24

the way down to the common bile duct.

0:26

And its central location and it

0:28

parallels the portal vein as well.

0:30

So this is biliary air.

0:32

So there is pneumobilia in this case.

0:35

As we come down, we'd expect that the patient,

0:37

maybe it has sphincterotomy, maybe you

0:39

know someone who's been in there before.

0:41

But in this case, we see a very collapsed gallbladder

0:44

with some air within the gallbladder as well.

0:47

Most patients who have a sphincterotomy

0:48

will have had cholecystectomy.

0:49

Not all of them, but you know most of them.

0:52

So as we keep on going, you can

0:53

notice a very strange appearance of

0:56

the base of the gallbladder here.

0:58

This might be better visualized on other planes.

1:01

And now we have a small bowel obstruction,

1:04

so we have to figure out what is the cause

1:06

for the small bowel obstruction.

1:09

Here have some thickened loops of small bowel as well.

1:11

And as we come up, if I can talk you into it,

1:14

we have an intraluminal foreign body right here.

1:17

Let's go on coronal.

1:19

Again, we have pneumobilia.

1:21

We have air within the gallbladder

1:23

lumen, and we can actually see some

1:25

fistulasation to the duodenal bulb here.

1:28

This, my friends, is the ever fun, not very

1:32

common, except for in textbooks, gallstone ileus.

1:36

So ileus is the wrong word to use

1:39

here, actually, that is a misnomer.

1:40

It should be gallstone obstruction.

1:42

You can see this thick wall over here, all the way up

1:45

to the obstructing element right in the middle there.

1:48

There are times that other foreign bodies

1:50

will obstruct the small bowel when ingested.

1:53

Um, I've seen a number of olives.

1:55

Chew your food and the like.

1:57

So gallstone ileus is a fun intraluminal

2:00

obstructing stone that will obstruct the

2:02

small bowel and will result in fistulasation

2:05

from the gallbladder to the small bowel.

2:08

And as a result, you'll get reflux of

2:10

air from the small bowel into the biliary

2:13

tree and result in beautiful pneumobilia.

2:16

So if you see a case of pneumobilia,

2:18

and obstruction where you have a gallbladder and it

2:21

all looks like it's fistula there, you wanna look for

2:23

your obstructing stone in the setting of gallstone

2:26

ileus. Always a fun diagnosis.