Pseudo-Riglerʼs Sign With Intrabiliary Reflux of Gastrografin Due to Severe Constipation

Abstract

Introduction: Rigler's triad, a manifestation of gallstone ileus, is constituted by the radiographic finings of ectopic gallstone, pneumobilia and small bowel obstruction. We report this very rare case of pneumobilia and reflux of oral Computerized Tomography (CT) contrast-Gastrografin into the biliary tree, in a patient with bowel obstruction/severe ileus due to constipation without an ectopic gallstone (pseudo-Rigler's sign). Patient was treated with colonic enemas, polyethylene glycol, and nasogastric tube decompression with resolution of these radiological findings. Case report: Here in, we present a case of a 58-year-old man with medical history of systolic congestive heart failure, coronary artery disease, chronic obstructive pulmonary disease, peripheral vascular disease who presented with hypoxic respiratory failure due to pneumonia. Patient was intubated and put on mechanical ventilation. Patient was found to have worsening abdominal distension. Physical examination revealed diminished bowel sounds. CT scan of abdomen and pelvis showed diffuse dilation of large and small bowel with abundant stool in the sigmoid colon and rectum, Gastrografin contrast in dilated intrahepatic bile ducts and pneumobilia (Figure 1). The patient was managed with high colonic enemas, polyethylene glycol and nasogastric tube decompression. Electrolytes and renal function were monitored and corrected accordingly. The patient subsequently had bowel movements with resolution of ileus and pneumobilia with contrast drainage from bile ducts.Figure: Intrahepatic ducts with gastrografin.Discussion: Constipation commonly occurs in the elderly population. Severe or chronic constipation can very rarely lead to fecal impaction, intestinal obstruction and pneumobilia. Our patient presented with atypical signs of Rigler's triad (barring the ectopic gallstone) in the setting of chronic constipation. Patient was also found to have reflux of oral contrast material from the duodenum via the ampulla into the common bile duct and dilated intrahepatic biliary tree- which is an extremely rare radiological finding. To our knowledge this is the first reported case of biliary reflux of oral in the setting of chronic constipation.