Successful Endoscopic Treatment of Bouveret Syndrome in a Patient with Choledochoduodenal Fistula Complicating Duodenal Ulcer

Choledochoduodenal fistula: a rare complication of acute peptic ulcer bleeding

A 75-year-old man presented with a 3-week history of melaena and right upper quadrant pain. This was on a background of significant alcohol intake and a complex medical history. He was haemodynamically unstable with investigations indicating a new iron-deficiency anaemia. After resuscitation, urgent intervention was required under general anaesthesia. This involved a triple phase abdominal CT, followed by emergency oesophagogastroduodenoscopy. This revealed deep ulceration with extension to the pancreatic head and common bile duct. There was also evidence of pneumobilia on CT, secondary to a choledochoduodenal fistula. Treatment encompassed an invasive and medical approach. Following treatment, the patient was stable, with follow-up endoscopy exhibiting good duodenal mucosal healing.

Complicating factors in the management of advanced Bouveret syndrome in frail and medically complex patients: Case report and discussion of pathophysiology

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Bouveret’s syndrome results from biliary stones from cholecysto-duodenal fistula.

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Gastric outlet obstruction from duodenal stones has high morbidity and mortality.

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Duodenal gallstones may grow over time, increasing risks of management.

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Delay in diagnosis and stone extraction may result in needing higher risk surgery.

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Tertiary referral of at-risk elderly or frail patients may improve outcomes.

Introduction

Bouveret Syndrome is a rare but important variant of gallstone ileus with high potential for morbidity and mortality. Bouveret syndrome is a complication of gallstone disease resulting from chronic inflammation and subsequent fistulization between the gallbladder and duodenum or stomach with subsequent impaction of the stone in the proximal GI tract. Here we present a case in an elderly man with moderate medical comorbidities.

Presentation of case

An elderly man presented to the hospital with symptoms of gastrointestinal obstruction. Upon further diagnostic work-up, he was noted to have a 5.8 cm gallstone impacted in his proximal GI tract and thus diagnosed with a rare variant of gallstone ileus—Bouveret syndrome.

Discussion

The therapeutic goal in approaching Bouveret syndrome is removal of the stone and improvement in obstruction and cholangitis. This may be accomplished with surgery or endoscopic therapy—although this may be less effective. Bouveret syndrome may have high morbidity.

Conclusion

Bouveret syndrome is a rare but potentially serious syndrome that should be managed accordingly. It should remain on the differential diagnosis of an elderly patient presenting with gastrointestinal obstructions, particularly if there is a history of gallstone disease and concern for proximal GI obstruction.

A Complicated Peptic Ulcer With Bleeding, Gastric Outlet Obstruction, and Choledochoduodenal Fistula

Although peptic ulcer disease (PUD) is a common entity, the rate of its complication has decreased with the advent of proton pump inhibitors. We present a case of complicated PUD in a 49-year-old male patient having a rare combination of bleeding, gastric outlet obstruction, and a large choledochoduodenal fistula (CDF) who presented with shock. After resuscitation and investigations, ligation of bleeder via duodenotomy, Roux-en-Y choledochojejunostomy, and gastrojejunostomy was done for ulcer bleeding, CDF, and pyloric stenosis respectively. The patient improved after surgery. As with other emergency surgery, minimizing morbidity and mortality remains the principle of management. The best treatment in this situation irrespective of hemodynamic stability is surgery, which is a one-time and best treatment for bleeding, obstruction, and CDF.