Bouveret's syndrome complicated by distal gallstone ileus after laser lithotropsy using Holmium: YAG laser

Gallstone ileus- A rare presentation in the era of rampant cholecystectomies

INTRODUCTION

Gallstone ileus is a rare but potentially dangerous complication of cholelithiasis and represents about 1 % of the total cases of small bowel obstruction (Balthazar and Schechter, 1978).

PRESENTATION OF CASE

We report a case of 40 years old female who presented with signs and symptoms of bowel obstruction. On further investigation, a diagnosis of gallstone ileus was established. She was managed by laparoscopy-assisted enterolithotomy.

DISCUSSION

Gallstone ileus, a form of mechanical intestinal obstruction, predominantly affects elderly females. Surgical management options includes enterolithotomy alone, two-staged enterolithotomy with delayed cholecystectomy and fistula repair, and single staged enterolithotomy and fistula repair. A laparoscopy-assisted enterolithotomy allows simultaneous direct diagnosis of gallstone ileus and assessment of pericholecystic adhesions along with cholecystoenteral fistula.

CONCLUSION

Laparoscopy-assisted enterolithotomy was chosen for managing gallstone ileus in this patient, omitting cholecystectomy and fistula repair due to dense adhesions. The patient remained symptom free for 6 months post-surgery, suggesting potential spontaneous closure of the cholecystoduodenal fistula, affirming the viability of this less invasive approach.

Bigger Than a Hen's Egg: A Case of Bouveret Syndrome

Bouveret syndrome, a rare complication of cholelithiasis resulting in gallstone ileus, presents diagnostic and therapeutic challenges due to its low incidence and nonspecific symptoms. We report a case of Bouveret syndrome in a middle-aged male without significant medical history, emphasizing the need for heightened clinical suspicion. Diagnostic imaging, including computed tomography and upper endoscopy, revealed gastric outlet obstruction and a cholecystoduodenal fistula. Treatment involved unsuccessful endoscopic lithotripsy followed by surgical intervention. This case underscores the importance of interdisciplinary collaboration for successful management. With no standardized approach, individualized treatment strategies, including endoscopic and surgical interventions, are crucial for favorable outcomes in Bouveret syndrome.

Bouveret Syndrome: A rare form of gallstone ileus a case report

INTRODUCTION AND IMPORTANCE

Bouveret Syndrome, a rare form of gallstone ileus, involves the migration and impaction of a gallstone in the duodenum or stomach, causing gastric outlet obstruction. Early intervention and a comprehensive care plan are essential for favorable outcomes.

CASE PRESENTATION

This article presents a case of an 82-year-old female with a history of coronary artery disease and untreated gallstones. The patient experienced nausea, vomiting, and abdominal pain for two weeks. Diagnostic procedures revealed a cholecystoduodenal fistula with a 4 cm stone lodged at the duodenojejunal angle. For our patient the gallstone was moved to the jejunum, followed by enterotomy and a latero_lateral gastroenteroanastomosis.

CLINICAL DISCUSSION

The rarity of Bouveret Syndrome and its nonspecific symptoms make diagnosis challenging, necessitating differentiation from other gastrointestinal disorders. Esophagogastroduodenoscopy (EGD) and imaging, such as computed tomography (CT), play crucial roles in diagnosis. In this case, the EGD did not show gallstones up to the second part of the duodenum. Management involves a multidisciplinary approach, with supportive care for stabilization and the primary goal of removing the impacted stone. Treatment options include endoscopic, surgical, or lithotripsy techniques. Bouveret Syndrome poses challenges due to its rarity, leading to delayed diagnosis. Prognosis varies based on factors such as stone size, location, and overall patient condition.

CONCLUSION

Through this case we emphasizes the importance of awareness, timely diagnosis, and appropriate management, with EGD and CT scan playing key roles in diagnosis. Surgical intervention remains a viable treatment option when endoscopic approaches are unavailable. The article highlights the controversial nature of fistula repair in Bouveret Syndrome.

Endoscopic treatment of Bouveret syndrome with a combination of electrohydraulic lithotripsy and balloon expansion: A case report

Bouveret syndrome is a rare type of ileus caused by the impaction of gallstones passing through a cholecystoenteric fistula in the duodenum. Endoscopic treatment with minimally invasive procedures is preferable for patients with this syndrome, typically for elderly individuals with a high surgical risk. Conventional endoscopic techniques often fail to remove impacted stones that are generally large and occasionally solid. We report the case of an 88‐year‐old bedridden woman with severe dementia who presented with difficulty in breathing. The patient was diagnosed with aspiration pneumonia. In addition, computed tomography showed a cholecystoduodenal fistula and a gallstone 37 mm in diameter that impacted the duodenal bulb. Bouveret syndrome was diagnosed on the basis of the computed tomography findings. The impacted stone was too large and hard to split with standard endoscopic lithotripsy using grasping forceps, mechanical lithotripter, polypectomy snare, basket catheter, and electrohydraulic lithotripsy (EHL). However, EHL with a dual‐channel therapeutic endoscope was achieved to drill a narrow hole approximately 20 mm deep into the stone, in four sessions. The stone was subsequently split by inflating the balloon, which was inserted into the hole, to 10 mm in diameter at 3 atm. All the split stones were spontaneously excreted during defecation after a few days. If the gallstone is too hard to fragment by endoscopic EHL alone, a combination of EHL and balloon expansion might be a useful alternative.

Gallstone ileus of the sigmoid colon: case report

Gallstone ileus is an uncommon cause of intestinal obstruction. It is caused when a gallstone migrates through an enterobiliary fistula (most often between the duodenum and the gallbladder) and is impacted in the digestive system, most often in the terminal ileum toward the ileocaecal valve.

Case Presentation

Here the authors report the case of a 74-year-old woman who was admitted to Compiegne Hospital in France for a gallstone ileus with the sigmoid colon as the impaction site, which is an even more rare cause of intestinal obstruction. The enterobiliary fistula was between the colon and the gallbladder.The gallstone was removed surgically with a colotomy, without treating the fistula, and after a failed endoscopic attempt to extract the stone. The follow-up was without complications, and a colposcopy showed spontaneous closure of the fistula after 6 weeks.

Discussion and Conclusion

The surgical closure of an enterobiliary fistula is an option that should be considered, but it can lead to higher morbidity. That is why the authors opted out of it, especially considering that spontaneous closure of the fistulae can happen, as it did in our case.

Endoscopic and surgical management of Bouveret's syndrome complicated by gallstone ileus

Bouveret’s syndrome is a rare complication that occurs most commonly in elderly patients with multiple comorbidities. It is secondary to an impacted gallstone causing gastric outlet obstruction from a cholecystoduodenal fistula, and there is no defined standardized management in current literature. A 92-year-old woman presents to our tertiary community hospital with abdominal discomfort concerning for bowel obstruction. Computed tomography revealed pneumobilia with a cholecystoduodenal fistula and a large gallstone in the proximal duodenum causing gastric outlet obstruction. The impacted gallstone failed endoscopic extraction with electrohydraulic lithotripsy, and patient subsequently developed distal gallstone ileus requiring exploratory laparotomy and enterolithotomy. This case report examines the need for early coordinated endoscopic and surgical management of a patient with Bouveret’s syndrome complicated by gallstone ileus as it is associated with high morbidity and mortality rates.

Endoscopic lithotripsy for Bouveret syndrome complicated by small bowel obstruction secondary to gallstone fragments

Bouveret syndrome is a rare complication of cholecystitis, in which impaction of a gallstone creates a cholecystoduodenal fistula leading to gastric outlet obstruction. We report a case of a 90-year-old female who presented with nausea and vomiting on a background of previous necrotic cholecystitis managed conservatively. Computed tomography of the abdomen demonstrated a large gallstone impacted in the third part of the duodenum leading to gastric outlet obstruction. Given her frailty, the patient underwent endoscopy to relieve the obstruction; however, complete retrieval of the gallstone fragments after lithotripsy was not possible. She subsequently developed distal gallstone ileus due to migration of the gallstone fragments and underwent laparotomy, enterotomy and retrieval of the fragments. This case highlights the dilemma of managing elderly patients with Bouveret syndrome with open or endoscopic surgery and the importance of retrieving all gallstone fragments after lithotripsy to avoid iatrogenic complications, such as gallstone ileus.

A Rare Case of Cholecystoduodenal Fistula with Rapid Distal Gallstone Migration

Patient: Female, 51-year-old

Final Diagnosis: Cholecystoduodenal fistula

Symptoms: Nausea • non-bilious emesis • right upper quadrant abdominal pain

Medication: —

Clinical Procedure: —

Specialty: Surgery

Bouveret Syndrome: A Rare Form of Gallstone Ileus

Bouveret’s syndrome is a rare variant of gallstone ileus characterized by a gastric outlet obstruction due to the impaction of a gallstone lodged in the duodenum, resulting from a cholecystoduodenal fistula. It accounts for only one to three percent of cases of gallstone ileus. We examine a case of Bouveret syndrome in an elderly Japanese female who presented with vomiting and decreased oral intake. Subsequent imaging found a gallstone ileus due to a bilioduodenal fistula. She underwent exploratory laparotomy enterolithotomy which found a large black gallstone located in the small bowel and confirmed the presence of the fistula. Despite its relative rarity, Bouveret syndrome carries a high risk of morbidity and mortality.

Case report - Bouveret's syndrome with pancreatitis: A rare combination

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High suspicion of Bouveret’s syndrome required in pancreatitis with persistent vomit.

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CT imaging or endoscopy are suitable tools to diagnose Bouveret’s syndrome.

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Endoscopy retrieval is first-line therapy as surgical mortality risk is 12–30%.

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90% of cases require surgical stone retrieval if cannot be removed endoscopically.

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Prolonged recovery can be expected as pancreatitis complicates patient’s management.

Introduction and importance

Bouveret’s syndrome is characterised by gastric outlet obstruction due to impaction of gallstone in the duodenum through a cholecystoduodenal fistula, having concurrent pancreatitis makes it an even rarer presentation.

Case presentation

We present an 82-year-old woman who presented with acute pancreatitis which she described 2 days of right upper quadrant pain with nausea and vomiting. Biliary obstruction signs were not present. She was known to have cholelithiasis but was for non-operative management due to significant cardiac history and multiple comorbilities.

Clinical findings and investigations

On initial examination, abdomen was soft with mild right upper quadrant tenderness. Murphy sign was negative. Lipase level was raised at 64,261U/L with cholestasis appearance on liver function test. Bouveret’s syndrome was later diagnosed on CT after symptoms of gastric outlet obstruction surfaced during her admission.

Interventions and outcome

An on-table endoscopic stone retrieval was done as first-line treatment. After multiple attempts of stone retrieval via endoscopy, surgical extraction of the impacted gallstone was required. Patient’s post-operative care was further challenged by effects from pancreatitis. Patient eventually recovered well and was discharged from hospital.

Relevance and impact

When managing patients with gallstone pancreatitis, presence of persistent vomiting should raise suspicion of Bouveret’s syndrome. Bouveret’s syndrome can be diagnosed in these patients with aid of CT imaging or endoscopy. Stone extraction is required to treat Bouveret’s syndrome, endoscopic retrieval is first-line therapy as surgery has mortality risk of 12–30%. Prolonged recovery period can be expected due to concurrent inflammatory effects from acute pancreatitis.

Bouveret Syndrome: A Systematic Review of Endoscopic Therapy and a Novel Predictive Tool to Aid in Management

BACKGROUND AND GOALS

Bouveret syndrome is characterized by gastroduodenal obstruction caused by an impacted gallstone. Current literature recommends endoscopic therapy as the first line of intervention despite significantly lower success rates compared with surgery. The lack of treatment efficacy studies and the paucity of clinical guidelines contribute to current practices being arbitrary. The aim of this systematic review was to identify factors that predict outcomes of endoscopic therapy. Subsequently, a predictive tool was devised to predict the success of endoscopic therapy and recommendations were proposed to improve current management strategies of impacted gallstones in the upper gastrointestinal tract.

METHODS

A systematic search of PubMed, Medline, Cochrane, and Scopus was performed for articles that contained the terms "Bouveret syndrome," "Bouveret's syndrome," "gallstone" AND "gastric obstruction" and "gallstone" AND "duodenal obstruction" that were published between January 1, 1950 to April 15, 2018. Articles were reviewed by 3 reviewers and raw data collated. χ and Kolmogorov-Smirnov tests were used to test associations between predictors and endoscopic outcomes. A logistic regression model was then used to create a predictive tool which was cross validated.

RESULTS

Failure of endoscopic therapy is associated with increasing gallstone length (P<0.0001) and impaction in the distal duodenum (P<0.05). Using multiple endoscopic modalities is associated with better success rates (P<0.05). The novel predictive tool predicted success of endoscopic therapy with an area under the receiver operating characteristic score of 0.86 (95% confidence interval: 0.79-0.94).

CONCLUSION

In Bouveret syndrome, a selective approach to endoscopic therapy can expedite definitive treatment and improve current management strategies.

Successful endoscopic treatment of a large impacted gallstone in the duodenum using laser lithotripsy, Bouveret’s syndrome: A case report

BACKGROUND

Bouveret´s syndrome is defined as a gastric outlet obstruction after passage of a gallstone through a fistula into the duodenum. Due to its rarity, the diagnosis of Bouveret’s syndrome is often delayed and causes a high morbidity and mortality rate.

CASE SUMMARY

A 93-year-old female presented with worsening pain in the right upper abdomen and vomiting. A gastroscopy revealed fluid retention caused by a massive obstructive stone in the bulbus. Endoscopic laser lithotripsy of the impacted stone was planned after multidisciplinary consultation. A Dornier Medilas H Solvo lithotripsy 350 µm laser fiber (10 Hz, 2 Joules) was used to disintegrate the stone into smaller pieces. The patient recovered completely.

CONCLUSION

A mechanical obstruction due to a gallstone that has entered the gastrointestinal tract is a complication that appears in 0.3%-0.5% of patients who have cholelithiasis. Stones larger than 2 cm can become impacted in the digestive tract, which occurs mostly in the terminal ileum. In approximately 1%-3% of cases, the stones cause obstruction in the duodenum. This phenomenon is called Bouveret’s syndrome. As this condition is mostly observed in elderly individuals with multiple comorbidities, treatment by an open surgical approach is unsuitable. Endoscopic removal is the preferred technique. The benefit of using laser lithotripsy is the precise targeting of energy onto the stone with minimal tissue injury. Endoscopic laser lithotripsy is a safe and feasible treatment option for Bouveret’s syndrome.

Bouveret's Syndrome: A Case-Based Review, Clinical Presentation, Diagnostics and Treatment Approaches

Gastric outlet obstruction that arises from gallstones impacted in the distal stomach or proximal duodenum after passing through a cholecystoduodenal, cholecystogastric or rarely choledocoduodenal fistula is called as Bouveret’s syndrome and it accounts for approximately 1-3% of all the patients with gallstone ileus. Although treatment modalities, including stone removal or fragmentation with classical endoscopic devices, such as snares, and forceps or fragmentation of gallstones with new devices, such as electrohydraulic lithotripsy, laser, extracorporeal shockwave lithotripsy have been described. However, only 29% of the patients benefit from nonsurgical methods. Removal of the stone through a gastrotomy or enterotomy and performing cholecystectomy and fistula repair with a second operation is an approach recommended for older patients with comorbid diseases. In this paper, a case of Bouveret’s syndrome was presented. The authors also aimed to review the diagnosis, management and treatment of this rare disease and to update the previous reviews.

Gallstone ileus: a review

Background Gallstone ileus is an important complication of cholecystolithiasis. In general, surgery is the treatment of choice for such cases, but clinicians face difficulty in the selection of an appropriate approach. Closure of a cholecystoenteric fistula can be achieved through one-stage or two-stage operation. Two-stage operation has a lower mortality rate than a one-stage procedure, but persistence of the cholecystoenteric fistula is associated with the risk of carcinogenesis and recurrence of gallstone ileus.

Objective This study reviews the different surgical approaches according to the impaction site of the gallstone, using data of previous studies by our group and clinical reports in the literature.

Conclusions First, for cases involving impaction at the duodenum, the cholecystoenteric fistula can be repaired in the same surgical field, and one-stage operation obtains favourable outcome; hence, one-stage operation is considered as treatment of choice. Second, for cases involving impaction at the small intestine, natural closure of the cholecystoenteric fistula or low mortality is expected; hence, two-stage operation may be performed, possibly using minimally invasive laparoscopy. Third, for cases involving impaction at the colon, natural closure of the cholecystocolonic fistula is unlikely, and patients have a high risk of reflux cholangitis due to faecal fluid; hence, one-stage operation is considered as treatment of choice.

A Multidisciplinary Approach to Management of Bouveret Syndrome

Bouveret Syndrome is a rare complication of gallstone disease that occurs when a gallstone enters the stomach or bowel through a biliary enteric fistula and becomes impacted, resulting in gastric outlet obstruction. It is frequently seen in elderly chronically ill patients with neglected biliary disease. We describe a multidisciplinary approach to management of Bouveret Syndrome that could be adopted by healthcare systems with resources commonly found in facilities with a general urologist and gastroenterologist or general surgeon. Successful application of laser lithotripsy under endoscopic guidance sufficiently fractured the stone to allow for disimpaction and relief of the gastric outlet obstruction.

Bouveret syndrome: current management strategies

Bouveret syndrome is a rare complication of cholelithiasis that usually presents with signs and symptoms of gastric outlet obstruction. Given the relative rarity of this condition, there are no standardized guidelines for the management of this condition. In this paper, we review the diagnosis and management options (endoscopic, laparoscopic, and open approaches) of patients with Bouveret syndrome, including a report of one case to illustrate some of the endoscopic and surgical principles of management.

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

Introduction

Cholecystoduodenal fistulas represent the most common type of bilioenteric fistulas while choledochoduodenal fistulas account for only 1–25% of cases. Bilioenteric fistula cases are associated with cholelithiasis and are rarely associated with duodenal peptic ulcers. Here we present the first case of Bouveret syndrome secondary to choledochoduodenal fistula complicating peptic duodenal ulcer managed successfully via endoscopic mechanical lithotripsy.

Case

86-year-old male with a medical history significant for coronary artery disease and stage 3 colorectal cancer status after resection and chemoradiation presented with intractable sharp abdominal pain worse postprandially for one week in duration, associated with early satiety, anorexia, and 5 lbs weight loss in one week. CT abdomen showed possible choledochoduodenal fistula and a distended stomach. An esophagogastroduodenoscopy (EGD) was performed revealing a large 2.5–3 cm stone lodged in the duodenal bulb at the base of duodenal ulcer with a fistula opening beneath it. The stone was extracted in 2 pieces via mechanical lithotripsy. Endoscopic ultrasound of the CBD revealed Rigler's triad.

Conclusion

Bouveret syndrome is mostly associated with cholecystoduodenal fistula and has high mortality and morbidity due to underlying comorbid conditions and elderly age. Patients are not always fit for surgical management, and endoscopic management is not always successful.

Gallstone Ileus Caused by Cholecystocolonic Fistula and Gallstone Impaction in the Sigmoid Colon: Review of the Literature and Novel Surgical Treatment with Trephine Loop Colostomy

Gallstone ileus is an uncommon cause of intestinal obstruction and occurs following the formation of a cholecystoenteric fistula, permitting passage of gallstones into the gastrointestinal tract. Impaction of a gallstone in the sigmoid colon is rare and is usually at sites of previous colonic disease. Definitive management can be challenging due to the advanced age and co-morbidity usually seen in this group of patients. We describe a patient successfully managed with on-table endoscopy and, under local anaesthetic, the formation of a left iliac fossa trephine loop colostomy, permitting an enterolithotomy to deliver the stone whilst accommodating for severe pre-existing distal sigmoid diverticular disease. A review of the literature identified various endoscopic and surgical treatments that, depending on local expertise and patient characteristics, can be considered on a case-by-case basis. We advocate the management described in this case for patients presenting with large bowel obstruction due to gallstone ileus, with a background of diverticular disease and who are not fit for general anaesthetic or formal bowel resection, as an alternative to medical palliation alone.

Novel treatment options for Bouveret's syndrome: a comprehensive review of 61 cases of successful endoscopic treatment

In Bouveret's syndrome, a biliary stone obstructs the duodenum. Surgical treatment is plagued by high morbidity and mortality. Therefore, endoscopic treatment has become a first-line approach. Areas covered: A literature search of Medline and Google Scholar databases was performed using the terms endoscopic treatment, non-operative treatment, Bouveret's syndrome, and gallstone ileus. Sixty-one cases of successful endoscopic treatment were found over the period 1978-2016 and are summarized herein. Therapeutic modalities used in 52 patients with complete success included mechanical lithotripsy (40% of cases), electrohydraulic lithotripsy (21% of cases), extraction of the intact stone and laser lithotripsy (15% of cases each), extracorporeal shockwave lithotripsy and duodenal stenting (4% of cases each). In the remaining 9 patients, stone fragments migrated distally and required surgical removal. Cholecystectomy was performed in five (8.2%) of 61 patients and gallbladder cancer was detected in three (4.9%) patients. Expert commentary: Meticulous preparation, including that of instruments, personnel, patient anesthesia, and X-ray availability, is key to success in this unusual situation. Partial success (stone fragmentation and mobilization to another location) may render surgery easier as these patients present with dense adherences in the right upper quadrant. Cholecystectomy is reserved for highly selected patients (e.g. relapsing ileus, gallbladder cancer).

Endoscopic treatment of Bouverets syndrome in an extremely elderly patient with Holmium: YAG laser

Bouveret's syndrome is a rare presentation of duodenal obstruction or gastric outlet obstruction caused by a large gallstone migrating through a cholecystoduodenal or choledochoduodenal fistula. Most patients are elderly and often have underlying comorbidities, complicating surgery. Endoscopic therapy should be used as first-line treatment for these patients who are not good surgical candidates. We report a case of a 98-year-old Chinese female who presented with vomiting for three days. Esophagogastroduodenoscopy and computed tomography confirmed the diagnosis of Bouveret's syndrome. The patient successfully underwent endoscopic lithotripsy with the Holmium: Yttrium- Aluminum-Garnet (Ho: YAG) laser. Ho: YAG laser lithotripsy has been used to treat Bouveret's syndrome in four case reports. It can be recommended in patients with Bouveret's syndrome who are poor candidates for surgery.

SIMILAR CASES PUBLISHED

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Gallstone ileus, clinical presentation, diagnostic and treatment approach

Gallstone ileus is a mechanical intestinal obstruction due to gallstone impaction within the gastrointestinal tract. Less than 1% of cases of intestinal obstruction are derived from this etiology. The symptoms and signs of gallstone ileus are mostly nonspecific. This entity has been observed with a higher frequency among the elderly, the majority of which have concomitant medical illness. Cardiovascular, pulmonary, and metabolic diseases should be considered as they may affect the prognosis. Surgical relief of gastrointestinal obstruction remains the mainstay of operative treatment. The current surgical procedures are: (1) simple enterolithotomy; (2) enterolithotomy, cholecystectomy and fistula closure (one-stage procedure); and (3) enterolithotomy with cholecystectomy performed later (two-stage procedure). Bowel resection is necessary in certain cases after enterolithotomy is performed. Large prospective laparoscopic and endoscopic trials are expected.

Recurrent gallstone ileus due to a residual gallstone: A case report and literature review

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Recurrence should be considered in all patients with gallstone ileus.

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A review of pre-operative imaging and meticulous inspection of the bowel and gallbladder should always be undertaken.

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Faceted gallstones should alert the surgeon to the potential presence of a second stone.

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Cholecystolithotomy should be considered as a safer alternative to cholecystectomy with fistula repair in high risk patients.

Introduction

Mechanical small bowel obstruction is an uncommon but important complication of cholelithiasis. Recurrent gallstone ileus has historically been considered a rare occurrence; however, the incidence is likely to be underreported and the condition carries a high mortality rate.

Presentation of case

We present a case in which a 67 year old man suffered a recurrence of gallstone ileus 10 days after his initial enterolithotomy, requiring further laparotomy.

Discussion

We review the literature to highlight potential clinical predictors as well as the benefits and pitfalls of management options in preventing repeated episodes of gallstone ileus in the same patient.

Conclusion

The presence of multifaceted gallstones and multiple stones of size ≥ 2cm on pre-operative imaging should alert the clinician to potential for recurrence.

Bouveret's syndrome: presentation of two cases with review of the literature and development of a surgical treatment strategy

BACKGROUND

Bouveret's syndrome causes gastric outlet obstruction when a gallstone is impacted in the duodenum or stomach via a bilioenteric fistula. It is a rare condition that causes significant morbidity and mortality and often occurs in the elderly with significant comorbidities. Individual diagnostic and treatment strategies are required for optimal management and outcome. The purpose of this paper is to develop a surgical strategy for optimized individual treatment of Bouveret's syndrome based on the available literature and motivated by our own experience.

CASE PRESENTATION

Two cases of Bouveret's syndrome are presented with individual management and restrictive surgical approaches tailored to the condition of the patients and intraoperative findings.

CONCLUSIONS

Improved diagnostics and restrictive individual surgical approaches have shown to lower the mortality rates of Bouveret's syndrome. For optimized outcome of the individual patient: The medical and perioperative management and time of surgery are tailored to the condition of the patient. CT-scan is most often required to secure the diagnosis. The surgical approach includes enterolithotomy alone or in combination with simultaneous or subsequent cholecystectomy and fistula repair. Lower overall morbidity and mortality are in favor of restrictive surgical approaches. The surgical strategy is adapted to the intraoperative findings and to the risk for secondary complications vs. the age and comorbidities of the patient.

Bouveret syndrome: gallstone ileus of the duodenum

This is a case of a 59-year-old woman with Bouveret syndrome. An initial endoscopic approach to management is described. Gallstone ileus occurs when a gallstone passes from a cholecystoduodenal fistula or a choledochoduodenal fistula into the gastrointestinal tract and causes obstruction, usually at the ileocecal valve. Bouveret syndrome is a variant of gallstone ileus where the gallstone lodges in the duodenum or pylorus causing a gastric outlet obstruction. The endoscopic and surgical management of this process are important to keep in mind and may be evolving as endoscopic therapies improve.

Laparoscopic-assisted enterolithotomy for gallstone ileus

Gallstone ileus is a rare complication of cholelithiasis seen usually in elderly population with comorbidities. Most of the cases present as acute intestinal obstruction with the diagnosis being made intraoperatively. There exists controversy regarding appropriate emergency surgical treatment of gallstone ileus as to whether biliary tract surgery should be done during the first operation. Laparoscopy in recent years is also being used for management of such cases. We report a case of gallstone ileus diagnosed preoperatively and successfully treated by laparoscopic-assisted enterolithotomy.

Bouveret's Syndrome: 64-Slice CT Diagnosis and Surgical Management-A Case Report

Gastric outlet obstruction caused by duodenal impaction of a large gallstone migrated through a cholecystoduodenal fistula has been referred to as Bouveret's syndrome. We present a case of gallstone-induced duodenal obstruction in an elderly female patient, diagnosed on a 64-slice MDCT scanner. One-stage surgery, that is, stone removal and cholecystectomy, was performed resulting in relief of obstruction and complete cure. Clinical features, multidetector computed tomography (MDCT) findings, and surgical management are discussed.

Bouveret's syndrome: a case report and a review of the literature

Bouveret's syndrome is a gastric outlet obstruction caused by an impacted gallstone that passes through a cholecysto-gastric or cholecysto-duodenal fistula. An elderly woman visited a local clinic with nausea and abdominal pain. Abdominal computed tomography revealed a stone that was impacted in the duodenal lumen and a fistula between the gallbladder and duodenum. Malignancy could not be excluded due to the mass in the cystic duct showing enhancement and the presence of enlarged lymph nodes on computed tomography, and increased fludeoxyglucose uptake in the cystic duct on positron emission tomography. The patient underwent simultaneous cholecystectomy, segmental duodenectomy and gastro-jejunostomy. Pathological examination exhibited chronic inflammation and no primary cancer of the gallbladder and fistula.

Successful Multimodality Endoscopic Treatment of Gastric Outlet Obstruction Caused by an Impacted Gallstone (Bouveret's Syndrome)

Bouveret's syndrome is a rare condition of gastric outlet obstruction resulting from the migration of a gallstone through a choledochoduodenal fistula. Due to the large size of these stones and the difficult location in which they become impacted, endoscopic treatment is unsuccessful and most patients require surgery. We report the case of an elderly male who presented with nausea and hematemesis, and was found on CT scan and endoscopy to have an obstructing gallstone in his duodenal bulb. After several endoscopic sessions and the use of multiple instruments including a Holmium: YAG laser and electrohydraulic lithotripter, fragmentation and endoscopic removal of the stone were successful. We believe this to be the first case of Bouveret's syndrome successfully treated by endoscopy alone in the United States. We describe the difficulties encountered which necessitated varied and innovative therapeutic techniques.

Gallstone ileus--clinical and therapeutic aspects

Gallstone ileus represents a rare (0.3-0.5%), but serious complication of a common illness--the gallbladder lithiasis and the incidence of this fascinating disease has remained the same over the years. The main actual characteristics of this pathology are the age over 65, the female gender (men/women ratio 1/5:1:10--due to the high rate of vesicular lithiasis) and the under 50% diagnostic established preoperatively. The frequency of gallstone ileus recurrence is of 4,7-5%. In this article, we discuss the pathogenesis of this illness presenting all the mechanisms described in the medical literature. The Rigler triad found at the abdominal CT-scan generally established the diagnosis. Still, in 25% of the cases we have a misdiagnosis because of the underestimation of the size of the gallstone. Finally, the treatment of gallstone ileus has had major changes from the past. We described the endoscopic and laparoscopic approach, which represents the modern treatment of this disease. Despite these diagnostic and therapeutic possibilities, the mortality remains high and the common causes are associated comorbidities and late presentation to the physician.

Bouveret's syndrome: case report and review of the literature

Bouveret's syndrome is defined as gastric outlet obstruction caused by duodenal impaction of a large gallstone which passes into the duodenal bulb through a cholecystogastric or cholecystoduodenal fistula. Initial attempts at endoscopic retrieval with or without mechanical or extracorporeal lithotripsy should be performed as first-line treatment, though success rates with endoscopic treatment are variable. We describe a case of Bouveret's Syndrome in an elderly patient that was successfully treated with endoscopic extraction combined with mechanical lithotripsy, and review the literature on this uncommon condition.

[A rare cause of gastric outlet obstruction: Bouveret's syndrome]

Bouveret's syndrome is a rare type of gallstone ileus in which a gallstone enters the intestinal tract via a cholecystoenteric fistula and is lodged in the duodenum or the stomach. Since the first description by León Bouveret in 1896, fewer than 200 cases have been described in the worldwide literature. Mortality is high, at 25%, but may be related to the advanced age of the typical patient and comorbidities, as well as diagnostic delay. Diagnosis may be made with radiological (abdominal X-ray, ultrasound, computed tomography or magnetic resonance imaging) and endoscopic techniques. Endoscopy is preferred as the first therapeutic option but is frequently unsuccessful and surgery is often required. We present the case of a patient admitted to hospital with a history of vomiting after eating and epigastric pain. The management of this rare cause of gastric outlet obstruction is discussed.

Intermittent gastric outlet obstruction due to a gallstone migrated through a cholecysto-gastric fistula: A new variant of “Bouveret’s syndrome”

Bouveret’s syndrome, defined as gastric outlet obstruction due to a large gallstone, is still one of the most dramatic biliary gallstone complications. Although new radiological and endoscopic techniques have made pre-surgical diagnosis possible in most cases and the death rate has dropped dramatically, “one-stage surgery” (biliary surgery carried out at the same time as the removal of the gut obstruction) should be still considered as the gold standard for the treatment of gallstone ileus.In this case, partial gastric outlet obstruction resulted in an atypical and insidious clinical presentation that allowed us to perform the conventional one-stage laparatomic procedure that completely solved the problem, thus avoiding any further complications.

Bouveret syndrome and gallstone ileus

Intestinal obstruction from gallstones is a rare complication of gallstone disease. These ectopic gallstones can cause obstruction anywhere from the duodenum to the colon and are accompanied by a cholecystoduodenal/enteric/colic fistula. We report an 81-year-old male who presented with gallstone obstruction of the duodenum who underwent attempted endoscopic fragmentation and extraction that eventually led to small bowel obstruction from an impacted fragment of the stone. He underwent successful enterolithotomy and has been asymptomatic from the cholecystoduodenal fistula. Surgery is the gold standard for the treatment of this condition but the extent of the operation remains a matter of debate.

Migrating gallstone: from Bouveret's syndrome to distal small bowel obstruction

Gallstone ileus is an uncommon cause of small bowel obstruction. When the gallstone lodges inside the duodenum and causes gastric outlet obstruction, it is termed Bouveret's syndrome. However, it is rather unusual to seen the evolution of a migrating gallstone (from duodenum to distal small bowel) in a patient during the same hospital admission. We report a case of gallstone ileus from the initial presentation of gastric outlet obstruction to the development of distal small bowel obstruction within the same hospital admission, and its total laparoscopic treatment.

Characterization of Bouveret's syndrome: a comprehensive review of 128 cases

AIM

The aim of the study was to characterize the clinical presentation, evaluation, and therapy of Bouveret's syndrome, by comprehensively reviewing all the identified previously reported cases, to facilitate early diagnosis and thereby to improve the prognosis.

METHODS

Relevant articles were identified by MEDLINE computerized searches, by consultation with all available reference books, and by review of the first author's teaching files. A new case in which the diagnosis of Bouveret's syndrome was missed at esophagogastroduodenoscopy (EGD)--despite endoscopic findings of gastric outlet obstruction caused by a hard, nonfleshy, and convex pyloric mass--prompted this review.

RESULTS

Review of 128 reported cases identified syndromic characteristics. Patients on average were 74.1 +/- 11.1 (SD) yr old. The female-to-male sex ratio was 1.86. Prominent symptoms were nausea and vomiting in 87%, abdominal pain in 71%, hematemesis in 15%, recent weight loss in 14%, and anorexia in 13% of patients. Prominent signs were abdominal tenderness in 44%, signs of dehydration in 31%, and abdominal distention in 26% of patients. Endoscopy revealed gastroduodenal obstruction in nearly all cases, but identified the obstructing stone in only 69%. Abdominal ultrasound or computerized tomography was diagnostic in about 60% of cases.

CONCLUSIONS

The following endoscopic findings are suggestive of Bouveret's syndrome: a dilated stomach containing old digested food from gastrointestinal obstruction together with a hard and nonfleshy mass at the obstruction. These endoscopic findings, in the setting of the currently reported characteristic epidemiologic and clinical findings, should strongly suggest this syndrome. Abdominal ultrasound or computerized tomography is recommended to confirm and extend the endoscopic diagnosis.

Successful Treatment of Bouveret Syndrome Using Holmium: YAG Laser Lithotripsy

Although gallstone disease is highly prevalent, cholelithiasis causing gallstone ileus is uncommon. Consideration has been given for nonoperative strategies to resolve obstruction due to the significant age and comorbidities afflicting this population. A 94-year-old man presented with a 5-day history of abdominal distension and tenderness. CT scan revealed multiple large gallstones within the gallbladder, pneumobilia, and two ectopic gallstones (antrum of the stomach and distal ileum). The patient was taken to the operating room where an enterolithotomy and gastrotomy was performed with removal of gallstones and subsequent relief of obstruction. During the postoperative course, the patient developed symptoms of gastric outlet obstruction and underwent gastrointestinal endoscopy for diagnosis and treatment. Two large gallstones, present in the duodenum, were retracted into the stomach using a Roth net but could not be retrieved beyond the upper esophageal sphincter. A holmium: yttrium-aluminum-garnet (Holmium: YAG) laser was used for fragmentation of the stones, with subsequent successful removal. This is the first documented successful use of the holmium: YAG laser for the treatment of recurrent gallstone ileus. Physicians should remember that in a small but important subgroup of patients, endoscopy accompanied by laser lithotripsy may prove beneficial.

Bouveret’s syndrome complicated by a distal gallstone Ileus

AIM: Gastric outlet obstruction caused by duodenal impaction of a large gallstone migrated through a cholecystoduodenal fistula has been referred as Bouveret’s syndrome. Endoscopic lithotomy is the first-step treatment. However, surgery is indicated in case of failure or complication during this procedure.

METHODS: We report herein an 84-year-old woman presenting with features of gastric outlet obstruction due to impacted gallstone. She underwent an attempt of endoscopic retrieval which was unsuccessful and was further complicated by distal gallstone ileus. Physical examination was irrelevant.

RESULTS: Endoscopy revealed multiple erosions around the cardia, a large stone in the second part of the duodenum causing complete obstruction, and wide ulceration in the duodenal wall where the stone was impacted. Several attempts of endoscopic extraction by using foreign body forceps failed and surgical intervention was mandatory. Preoperative ultrasound evidenced pneumobilia whilst computerized tomography showed a large stone, 5 × 4 × 3 cm, logging at the proximal jejunum and another one, 2.5 × 2 × 2 cm, in the duodenal bulb causing closed-loop syndrome. She underwent laparotomy and the jejunal stone was removed by enterotomy. Another stone reported as located in the duodenum preoperatively was found to be present in the gallbladder by intraoperative ultrasound. Therefore, cholecystoduodenal fistula was broken down, the stone was retrieved and cholecystectomy with duodenal repair was carried out. She was discharged after an uneventful postoperative course.

CONCLUSION: As the simplest and the least morbid procedure, endoscopic stone retrieval should be attempted in the treatment of patients with Bouveret’s syndrome. When it fails, surgical lithotomy consisting of simple enterotomy may solve the problem. Although cholecystectomy and cholecystoduodenal fistula breakdown is unnecessary in every case, conditions may urge the surgeon to perform such operations even though they carry high morbidity and mortality.