Well, that was an abdominal x-ray of the lady who presented to us.
The arrow points to the dilated gallbladder filled with air. Air within the gallbladder can only come from the intestine and thus there must be an abnormal connection between the gallbladder and the intestine. This is either to the small intestine(bowel) or the large intestine. This is called a fistula.
This is a rare condition and even more so at present when laparoscopic surgery is done often so commonly! However, I have seen 5 to 6 to date and 4 in Selayang itself! This is due to long standing disease of the gallbladder which becomes inflammed and adherent to the surrounding structure and then erodes that structure.
The stone which is usually large will then pass through and obstructs the small intestine at its narrowest lumen that is the ileocaecal valve where the small intestine enters the large intestine. Stones that enters the large intestine through a fistula with the large intestine are often passed out without any problems.
Surgery is performed to relieve the obstructed bowel by making an incision over the bowel where the stone is and remove the stone. This is a relative simple surgery.
Since surgery is the only option for the obstructed bowel, thus the issue that arise is should one proceed to remove the diseased gallbladder and repair the fistula at the same sitting? This issue occurs because many at times the patients who present with this problem are elderly with many other health problems.
I tend to remove the diseased gallbladder and repair the fistula if it is not too difficult. But this is done based on how well the patient is tolerating the surgery. There are some who will do this part of the surgery later or never do it at all.