Bouveret syndrome: current management strategies

Bouveret's syndrome: A rare case of gallstone causing gastric outlet obstruction

Key Clinical Message

The case highlights the importance of decisive action in addressing large gallstones causing gastric outlet obstruction. The chosen single-stage surgical approach reflects the need to manage both obstruction and the gallstone simultaneously.

Abstract

Bouveret's syndrome is a rare cause of gastric outlet obstruction secondary to gallstones entering the enteric system through an acquired cholecystoduodenal fistula. Here, we present the case of an 85-year-old female who presented to our emergency department with gastric outlet obstruction secondary to a large gallstone in the third part of the duodenum. Abdominal X-ray did not demonstrate air-fluid levels but revealed a dilated gastric shadow, suggesting gastric outlet obstruction. EGD showed a dilated stomach and a hard, golf ball-sized gallstone in the duodenum. CT scan showed a distended stomach with a large gallstone obstructing the DJ junction and air in the biliary tree. Findings were suggestive of perforation of the gallbladder with stone impaction in the duodenojejunal (DJ) junction. The patient was managed surgically with a one-stage procedure comprising enterotomy, fistula closure, and cholecystectomy. Although Bouveret's syndrome is rare, it is important for practicing surgeons to have a high index of suspicion for this condition due to the high mortality associated with it.

Surgical Strategy in Bouveret's Syndrome: Report of a Case With One-Stage Surgery

Bouveret's syndrome is a rare condition caused by a gallstone that impacts the duodenum via a cholecystoduodenal fistula and obstructs the gastric outlet. Despite its high mortality rate, the treatment strategy for Bouveret's syndrome is debatable and frequently challenging. The main issue is whether cholecystectomy and fistula repair following stone extraction should be performed concurrently with one-stage surgery. We present a case of Bouveret's syndrome that was treated with one-stage surgery using a bailout procedure.

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.

A rare case of a cholecysto-duodenocolonic fistula secondary to cholelithiasis

Internal biliary fistula is a rare but well-known complication of cholelithiasis. It is a notoriously challenging entity to diagnose and manage. Gallstones are often the causative factor in the formation of a cholecystoenteric fistula, with the most common internal biliary fistula being a cholecystoduodenal fistula followed by a cholecystocolonic fistula. Rarely, do these fistulae exist simultaneously. Here, we present an uncommon case of cholecysto-duodenocolonic fistula.

Bouveret's syndrome: An old diagnosis. A modern multimodality approach (endoscopic and robotic surgical) of gastric outlet obstruction: Report of two cases

INTRODUCTION AND IMPORTANCE

Bouveret's syndrome is an uncommon condition characterized by the impaction of a gallstone in the pylorus or duodenum via a cholecysto-enteric fistula causing gastric outlet obstruction. We report two unusual cases of Bouveret's syndrome causing gastric outlet obstruction in two elderly patients.

CASE PRESENTATION

Two elderly female patients presented to the surgical assessment unit with features of gastric outlet obstruction. In both cases, an urgent computed tomography (CT) of the abdomen showed pneumobilia, gastric distension, and gallstones impaction at the duodenal bulb. In Patient 1, endoscopic removal of the impacted gallstones was done successfully. She was discharged three days following an uneventful recovery. In Patient 2, an endoscopic removal of a single large gallstone was attempted, which was unsuccessful. She underwent robotic gastrotomy with extraction of the large gallstone with primary repair. She was discharged on 8th postoperative day.

CLINICAL DISCUSSION

Treatment options for Bouveret's syndrome include endoscopic management and surgery. The selection of treatment options depends upon factors like the degree of obstruction, the impaction site, number, type or size of gallstones, patient co-morbidities and clinical parameters at presentation, as well as expertise available, both endoscopic and surgical.

CONCLUSIONS

Bouveret's syndrome is one of the rare complications of gallstone. Endoscopic management can be effective at removing the impacted gallstones, which is particularly helpful for those elderly patients who have multiple medical co-morbidities, as in our first patient. Surgical management like minimal invasive surgery (robotic) can be beneficial in failed endoscopic attempt of removal of stone like in the second patient.

Upper gastrointestinal bleeding revealing a Bouveret syndrome: A case report

Bouveret's syndrome is an uncommon cause of gastrointestinal obstruction. It's a result of the passage of a gallstone through a fistula connecting the gallbladder with the duodenum or stomach. The diagnosis is challenging due to its atypical clinical manifestations. There have been a few reported cases of Bouveret syndrome presenting with gastrointestinal bleeding. Treatment options include both endoscopic and surgical approaches. We present the case of a 92-year-old woman admitted to the emergency department for upper gastrointestinal bleeding. Gastroscopy revealed gastric stasis upstream of a calculus inducing an obstruction of the bulb. The computed tomography (CT) scan showed a cholecystoduodenal fistula with a calculus lodged in the bulb. The patient underwent a gastrostomy with extraction of the calculus. Postoperative course was uneventful and the patient was discharged home. In the majority of cases, Bouveret's syndrome is revealed by an upper gastrointestinal obstruction, but other signs, such as gastrointestinal bleeding, can be seen. The diagnosis is confirmed by an imaging method that highlights Rigler's triad. The management can be either endoscopic or surgical depending on the patient's general condition. The diagnosis is often difficult due to the lack of specificity in the symptoms. Presently, there exists no consensus concerning the appropriate approach for its management.

Endoscopic management of Bouveret syndrome with electrohydraulic lithotripsy

Video 1Endoscopic management of Bouveret syndrome with electrohydraulic lithotripsy.

Bouveret Syndrome: A Rare Case of Gastric Outlet Obstruction Caused by an Impacted Gallstone

Bouveret syndrome is a rare condition where a gallstone obstructs the gastric outlet. This report discusses its diagnosis, management, and the need for further research. Prompt recognition is crucial to prevent complications. CT scan with oral contrast aids in diagnosis. Treatment options include conservative measures, endoscopy, or surgery. A multidisciplinary approach is essential for successful management. More research is needed to understand this condition fully.

Imaging spectrum of non-neoplastic and neoplastic conditions of the duodenum: a pictorial review

Given its crucial location at the crossroads of the gastrointestinal tract, the hepatobiliary system and the splanchnic vessels, the duodenum can be affected by a wide spectrum of abnormalities. Computed tomography and magnetic resonance imaging, in conjunction with endoscopy, are often performed to evaluate these conditions, and several duodenal pathologies can be identified on fluoroscopic studies. Since many conditions affecting this organ are asymptomatic, the role of imaging cannot be overemphasized. In this article we will review the imaging features of many conditions affecting the duodenum, focusing on cross-sectional imaging studies, including congenital malformations, such as annular pancreas and intestinal malrotation; vascular pathologies, such as superior mesenteric artery syndrome; inflammatory and infectious conditions; trauma; neoplasms and iatrogenic complications. Because of the complexity of the duodenum, familiarity with the duodenal anatomy and physiology as well as the imaging features of the plethora of conditions affecting this organ is crucial to differentiate those conditions that could be managed medically from the ones that require intervention.

The Rolling Stone: Bouveret Syndrome Requiring Open Gastrotomy After Failing Electrohydraulic Lithotripsy

Bouveret syndrome (BS) is an extremely rare form of gallstone ileus where a stone travels through a biliary-enteric fistula and causes gastric outlet obstruction. A 92-year-old male presented with gastric outlet obstruction secondary to an impacted gallstone in the duodenal bulb seen on imaging. Endoscopic therapy failed twice due to the immense gallstone size, and an open gastrotomy was required to remove the stone. The procedure was successful; however, the patient, unfortunately, passed away days after the operation due to other hospital illnesses. BS should be considered in patients with advanced age and significant comorbidities presenting with gastric outlet obstruction.

No Stone Left Unturned: Bouveret Syndrome Treated With Electrohydraulic Lithotripsy and Open Extraction With Pyloric Exclusion and Gastrojejunostomy

Bouveret syndrome is ectopic gallstone impaction and obstruction of the duodenum or pylorus affecting a small minority of gallstone ileus cases. There have been advances in its endoscopic management, but this remains a challenging condition to treat successfully. We present a patient with Bouveret syndrome who required open surgical extraction and gastrojejunostomy after attempts of endoscopic retrieval and electrohydraulic lithotripsy (EHL). A 79-year-old man with a medical history of gastroesophageal reflux disease, chronic obstructive pulmonary disease on 5 liters of oxygen at baseline, and coronary artery disease with recent stenting presented to the hospital with three days of abdominal pain and vomiting. CT of the abdomen/pelvis demonstrated gastric outlet obstruction, a 4.5 cm gallstone in the proximal duodenum, cholecystoduodenal fistula, gallbladder wall thickening, and pneumobilia. Esophagogastroduodenoscopy (EGD) demonstrated a black pigmented stone impacted in the duodenal bulb with ulceration of the inferior wall. Repeated Roth net retrieval attempts of the stone were unsuccessful even after biopsy forceps were used to trim the stone's margins. The next day, EGD with EHL used 20 shocks of 200 watts, allowing for partial stone removal and fragmentation, but the majority of the stone remained stuck to the wall. Laparoscopic cholecystectomy was attempted but was converted to an open extraction of the gallstone from the duodenum, pyloric exclusion, and gastrojejunostomy. The gallbladder remained in place, and the cholecystoduodenal fistula was not surgically repaired. The patient experienced significant postoperative pulmonary insufficiency and remained on the ventilator with failure of multiple spontaneous breathing trials. Postoperative imaging showed resolution of pneumobilia but a small amount of contrast leaked from the duodenum revealing the fistula's persistence. After 14 days of unsuccessful ventilator weaning, the family opted for palliative extubation. Advanced endoscopic techniques have been regarded as the first-line intervention for Bouveret syndrome as there is low morbidity and mortality associated with them. However, there is a reduced success rate compared to surgical intervention. Open surgical management has high morbidity and mortality in the elderly and comorbid patients commonly affected by this condition. Thus, the risks and benefits must be weighed and individualized for each patient with Bouveret syndrome before therapeutic intervention.

Multiple Cholecystoenteric Fistulae With Bouveret Syndrome and Acute Pancreatitis: A Rare Combination

Multiple cholecystoenteric fistulae, Bouveret syndrome (a form of gallstone ileus), and acute pancreatitis occurring together is very rare. Diagnosis is seldom clinical and is mostly based on computerised tomography (CT) or magnetic resonance imaging (MRI). Endoscopy and minimally invasive surgery have revolutionised the treatment of Bouveret syndrome and cholecystoenteric fistula, respectively, over the last two decades. Laparoscopic repair of cholecystoenteric fistula followed by cholecystectomy is successful on a consistent basis with skilled laparoscopic suturing and advanced laparoscopy. In patients with Bouveret syndrome, when the stone is <4cm and is in the proximal duodenum, it is usually amenable for endoscopic extraction with snares, nets, forceps and lithotripsy. When endoscopy is unavailable or fails, laparoscopic surgery is suitable for these patients. However, stones >4 cm, located in the distal duodenum, multiple fistulae, and associated acute pancreatitis may necessitate open surgery. We present here a case of a 65-year-old Indian female with multiple cholecystoenteric fistulae and Bouveret syndrome with acute pancreatitis with a 6.5 cm gallstone diagnosed on CT scan and MRI and treated successfully by open surgery. We also review the current literature on the management of this complex problem.

A Case of Bouveret's Syndrome Treated With Holmium:Yttrium-Aluminum-Garnet Laser

Bouveret's syndrome is a rare form of gallstone ileus described as a gastric outlet obstruction from a gallstone that travels from the gallbladder to the bowel through a bilioenteric fistula. Despite its rarity, the mortality rate of this condition is high. Endoscopic treatment is preferred over surgery due to the association with lower mortality rate. To date, there are limited data about the application of holmium:yttrium-aluminum-garnet (YAG) laser lithotripsy for fragmentation of gallstones in Bouveret's syndrome. We present the case of a 74-year-old man with multiple cardiac comorbidities who presented with periumbilical pain, decreased appetite, and vomiting. The patient had previously been admitted three months prior with acute cholecystitis, and a cholecystostomy tube was placed. He had leukocytosis and purulent discharge in his cholecystostomy bag. Computed tomography (CT) scan of the abdomen and pelvis showed a change in the position of a previously seen large gallstone from the neck of the gallbladder on the last admission, to the lumen of the duodenal bulb on this admission. This indicated the development of a cholecystoduodenal fistula, with the stone passing through this fistula into the duodenal bulb, causing the complete obstruction. Endoscopic treatment was recommended by the surgery team due to cardiac comorbidities and the significant friability of the tissue requiring laparotomy. Initial endoscopic evaluation showed complete obstruction of the duodenal bulb by a large smooth stone, not allowing passage of a guidewire beyond the stone. Therefore, holmium:YAG laser lithotripsy was used. After two sessions of laser therapy, four days apart, each breaking a pigmented and calcified stone, it eventually passed through the small bowel into the colon, relieving the obstruction. The patient had a favorable outcome and did not require surgery. This case report shows that holmium:YAG laser lithotripsy is capable of delivering favorable outcomes, as seen in a patient with a heavily calcified and pigmented stone, older age, and multiple comorbidities. Holmium:YAG laser could be considered for use with endoscopic equipment for future management of this condition, especially in patients who have medical comorbidities and heavily calcified gallstones.

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.

Bouveret syndrome: a rare complication of gallstone disease

A Caucasian man in his late 80s was admitted with central abdominal pain, abdominal distension and continuous vomiting, on the background of a recent admission for acute cholecystitis. The patient was managed for subacute bowel obstruction and was admitted to general surgery for further investigation. His blood tests showed raised inflammatory markers and deranged liver function tests. A CT scan showed the migration of a large gallstone, previously seen in the neck of the gallbladder on prior admission, to the proximal duodenum causing a degree of gastric outlet obstruction. A diagnosis of Bouveret syndrome was made, and although initially managed conservatively, the patient ultimately underwent surgery to remove the gallstone which had relocated again to the terminal ileum. Our case highlights the importance of considering rare complications such as Bouveret syndrome in patients presenting with bowel obstruction, particularly in the context of recent or chronic cholecystitis.

A rarer cause of Bouveret syndrome - A case report

INTRODUCTION AND IMPORTANCE

Bouveret syndrome is a rare type of gallstone ileus causing gastric outlet obstruction with high morbidity and mortality risk, and hence important to have a high degree of clinical suspicion on presentation for prompt diagnosis and management.

CASE PRESENTATION

We present a case of an elderly woman with abdominal pain, haematemesis, and an unremarkable radiograph whose initial emergent endoscopy showed a gastric obstruction and a duodenal diverticulum with a non-bleeding broad based duodenal ulcer. Subsequent computerised tomographic (CT) scan revealed a cholecystoduodenal fistula and gastric outlet obstruction secondary to a 5 cm stone in the duodenojejunal (DJ) flexure. A repeat endoscopy was attempted for endoscopic removal prior to proceeding to open enterolithotomy.

CLINICAL DISCUSSION

This case highlights the challenges in diagnosis and discusses the latest literature on multimodal management consisting of endoscopy and surgery.

CONCLUSION

The location of the obstructing stone at the duodenojejunal flexure is extremely rare and therefore will add to world literature on Bouveret syndrome.

Endoscopic holmium laser lithotripsy for therapy of Bouveret syndrome

Video 1Video of holmium laser lithotripsy procedure.

Synchronous Gallstone Ileus and Bouveret’s Syndrome: A Report of Two Rare Concurrent Complications of Gallstone Disease

Cholecystoenteric fistulas occur as a result of a chronic inflammatory insult involving the gallbladder and the erosion of both its wall and a bowel segment. When the fistula develops, it creates a pathway for gallstones to migrate and cause an intestinal obstruction, known as gallstone ileus. When it obstructs the gastric outlet, a proximal variant of gallstone ileus occurs, known as Bouveret's syndrome. A 65-year-old man presented to the emergency department with a three-day history of epigastric and right upper quadrant pain and persistent vomiting, preceded by unintentional weight loss of 15 kg over three months. Endoscopic and complementary imaging studies identified a concurrent gastric outlet obstruction caused by a lodged gallstone in the duodenal bulb and gallstone ileus. The patient underwent an urgent exploratory laparotomy and was submitted to an enterolithotomy and gastrolithotomy. Due to a sudden deterioration on the fourth postoperative day, he underwent an emergent re-laparotomy that found fecal peritonitis and complete dehiscence of both closures. The patient was then managed with damage control surgery. An atypical gastric resection and enterectomy of the distal ileum were performed and the patient was admitted to the intensive care unit in temporary abdominal closure (laparostomy). The patient failed to improve and died on the same day. Ultimately, the patient's multiple comorbidities, including morbid obesity, malnutrition, and diabetes, contributed to poor tissue healing and the fatal outcome. Gallstone ileus and Bouveret's syndrome are two rare complications of cholecystoduodenal fistulas that have not yet been reported to occur simultaneously. Both intestinal and gastric obstruction makes the surgical approach the first-line treatment.

Different Approaches to the Management of Cholecystoenteric Fistula

A cholecystoenteric fistula is an anomalous communicating tract between the gallbladder and any segment of the gastrointestinal tract. It is a rare complication of gallstone disease and typically affects elderly patients with multiple medical comorbidities. These fistulae can present in a variety of ways, and the diagnosis is often made only after extensive workup. Despite notable advances in imaging techniques in the last half-century, a considerable number of cases are still discovered incidentally during open or laparoscopic surgery. We present a series of 3 cases, each with different etiologies and presentations, but all of whom were found to have a cholecystoenteric fistula. Each case was managed differently, highlighting the diversity of this intriguing condition.

Bouveret Syndrome in a Cirrhotic Patient

Here, we present a case of Bouveret syndrome, a rare etiology of gallstone impaction in the setting of chole-enteric fistula, in a cirrhotic patient. This syndrome is most often seen in elderly patients with multiple comorbidities and as such has high morbidity and mortality rates. Because of its prevalence in this patient population and its rarity, there are no established guidelines for the workup and management of this disease. We discuss currently available options for management and thoughts on our comorbid patient and her clinical course.

Successful endoscopic management of Bouveret syndrome

We present a frail 83-year-old female with Bouveret syndrome managed using an endoscopic approach. Our patient attended the emergency department with abdominal pain, vomiting and signs of sepsis. She had a recent admission with acute cholecystitis that which had been managed conservatively. Axial imaging revealed aerobilia with a 14 mm common bile duct and a 3.5 cm calculus impacted in the duodenum, in association with a cholecysto-duodenal fistula. After resuscitation, an oesphagoduodenoscopy was performed under general anaesthesia. The large stone was seen impacted in the first part of duodenum. Mechanical lithotripsy and the Kudo snare were employed to fragment the stone and remove large fragments. Bouveret syndrome is rarely managed with success through endoscopy. The syndrome typically occurs in frail, elderly co-morbid patients who would benefit from endoscopic management over open surgery. Despite low success rates historically, endoscopic management is a reasonable and viable option in cases of Bouveret syndrome.

Developments in the Diagnosis and Management of Cholecystoenteric Fistula

Background: Cholecystoenteric fistula (CEF) is a rare complication of cholelithiasis. CEF refers to one or more pathological perforations between the gallbladder and the adjacent gastrointestinal tract, first described by Bartholin in 1645. The aim of this review is to examine the etiology, symptoms, diagnosis, and treatment of CEF.Methods: A literature search was conducted according to a set of criteria in PubMed for historical and current peer-reviewed studies regarding CEF.Results: Clinical manifestations of CEF are always latent. Despite modern imaging studies and diagnostic methods, it is still very difficult to definitively diagnose CEF preoperatively. Instead, CEF is often accidentally discovered in the perioperative period or via intraoperative exploration.Conclusions: Without appropriate preoperative preparation, gastrointestinal injury and intraoperative bleeding often occur. CEF often goes unreported, and its diagnosis and treatment are still controversial. Early diagnosis of CEF is essential for effective treatment and improved outcome.

Bouveret’s Syndrome: A Case Series and Literature Review on a Gallstone Disease Causing Gastric Outlet Obstruction

Introduction

Bouveret’s syndrome refers to a gastric outlet obstruction due to the impaction of a large gallstone following retrograde migration via a bilio-duodenal fistula. Although no clear management guideline has been formulated, different treatment modalities have been described, including endoscopic stone removal using classical endoscopic devices, like snares and forceps, or fragmentation of stones with new devices, such as lasers and extracorporeal shockwave lithotripsy (ESWL).

Results

This case series reports six patients who have been diagnosed with Bouveret’s syndrome and have presented with interesting radiological and endoscopic findings. The report is followed by a literature review, including diagnostic and management options for this rare condition.

Discussion

Cholelithiasis is a common condition occurring in the general population and may develop rare complications such as cholecystoduodenal fistula. Bouveret’s syndrome presents with a clinical picture similar to that of gastric outlet obstruction, and laboratory findings are often consistent with an obstructive jaundice picture. The use of endoscopic treatment with a range of different lithotripsy modalities has been described to manage this condition.

Conclusion

The diagnosis of Bouveret’s syndrome is made after performing appropriate imaging studies. The first-line management option is endoscopic treatment. If this fails, surgical intervention is recommended.

Evaluation of gallstone classification and their diagnosis through serum parameters as emerging tools in treatment: a narrative review

The treatment of gallstones is a matter of real concern as they may cause gallbladder cancer if not properly attended to. Evaluating the classification of gallstones can give major clues in their treatment as it will decide their aetiology, chemical composition, and pathogenesis. Also, serum parameters have emerged as an efficient tool for diagnosing gallstones. They can be probed to evaluate different biochemicals and the changes in their levels in gallstone patients which can be correlated with early prediction of the formation of gallstones. In the present review, a thorough search of the available literature was done starting from the earliest approaches for the classification of gallstones up to the recent advancements. The alteration in the level of serum parameters was also studied in gallstone patients so that it can act as a potential diagnostic tool for early detection of gallstone formation. The earliest classification of gallstones was done in 1896 by Nauyn. He classified them into pure cholesterol stones, laminated cholesterol stones, ordinary gallbladder stones, mixed bilirubin stones, and rare forms. The most recent classification of gallstones was done by Peter et al in 2020 and they classified them as pure, mixed, composite cholesterol, carbonate stones, black and brown pigment stones. The altered of levels of serum parameters was analyzed by Reuben (1985) and in recent times by Peter et al (2020). The various serum parameters studied were as RDW-CV test (red blood cell distribution width), PCT (prolactin) test, MPV (mean platelet count), LYM (lymphocyte) test, and EOS (eosinophil and eosinophil count test). Also, we discussed some practical considerations for gallstones that can be taken into account for gallstone prevention and diagnosis. Further research is required to detect gallstone type in the gallbladder by using the alteration in the levels of serum parameters.

Mirizzi Syndrome With Bouveret Syndrome: A Rare Amalgam

Mirizzi and Bouveret syndromes are uncommon but important complications of calculous cholecystitis. Mirizzi syndrome commonly presents with jaundice due to extrinsic compression on the common bile duct by an impacted stone at the gall bladder infundibulum, whereas Bouveret syndrome presents with gastric outlet obstruction due to a large stone in the duodenum. Our case is a 65-year-old lady who presented with pain in the right upper abdomen associated with nausea and vomiting. Contrast-enhanced computed tomography and MRI of the abdomen were suggestive of calculus in the infundibulum of the gall bladder with compression over the common bile duct and a large stone in the first part of the duodenum. Upper gastrointestinal endoscopy confirmed the findings but could not retrieve the stone. Cholecystectomy with the retrieval of calculus from the infundibulum and duodenum was performed with the closure of the fistulous opening. The patient did well in the post-operative period and is doing well after nine months of follow-up. Chronic calculus cholecystitis can present in varied forms, and one should be aware of such rare complications and their management.

Cholecystogastric fistula in Bouveret syndrome: Case report and literature review

INTRODUCTION AND IMPORTANCE

Cholelithiasis is the benign bile pathology with major prevalence. A rare condition has been described, when a stone migrates through the duodenum causing small bowel obstruction (SBO), it's known as Bouveret syndrome, and it's attributed to almost 5% of SBO. Just 2% of the cases present with the migration of the stone through a fistula between gastric chamber and gallbladder, with limited reports in the literature.

CLINICAL FINDINGS

We present a case of an 87-year-old male with Bouveret syndrome and a cholecystogastric fistula with a stone in the gastric chamber who underwent laparoscopic gastrotomy to resolve the clinical case.

CONCLUSION

Bouveret syndrome remains to be a rare condition in benign bile pathology. Individualized treatment should be performed and multidisciplinary approach leads to improved outcomes for the patient.

A Path Less Travelled: A Case Report of an Unusual Trip of a Gall Stone

Gall stone ileus is one of the rare complications of patients with cholelithiasis and usually affects elderly females. The usual sites for the stone to get impacted are the distal ileum and ileocaecal valve. Computed tomography (CT) remains diagnostic and surgery is the treatment of choice. A 60-year-old diabetic female, who was diagnosed with gall stone-induced pancreatitis one month ago, presented to the surgical emergency department with complaints of right upper abdominal pain with recurrent vomiting and constipation of five days duration. The patient was managed conservatively. A provisional diagnosis of subacute intestinal obstruction was kept and a barium meal follow-through (BMFT) was requested. However, BMFT was inconclusive. After two weeks, she presented again to the emergency department with clinical features of subacute intestinal obstruction. The patient was planned for exploratory laparotomy in view of recurrent episodes of obstruction and the presence of peritonism. Intraoperatively, we encountered a cholecystogastric fistula with a gall stone of size approximately 6.5x4 cm impacted at approximately 60 cm from the ileocaecal junction and dilated proximal small bowel loops. The surgical procedure comprised enterolithotomy and cholecystectomy along with repair of cholecystogastric fistula done. The patient had an uneventful postoperative course. Gall stone ileus is a rare cause of small bowel obstruction. Gall stone ileus presenting with a recent history of pancreatitis further makes the suspicion very unlikely.

Gallstone Ileus in Octogenarians: Is Cholecystectomy Really Needed?

Gallstone ileus is an uncommon complication of cholelithiasis and occurs when a gallstone migrates through a cholecystoenteric fistula and impacts within the gastrointestinal tract. Surgical intervention remains the treatment of choice, which consists of a full-thickness incision of the visceral wall and removal of the impacted gallstone. In this paper we present the treatment approach of 6 cases of gallstone ileus in octogenarians. In our cohort, intestinal obstruction was resolved through an enterotomy or gastrotomy and lithotomy/stone extraction in every patient. No cholecystectomies were undertaken. Despite the fact that gallstone ileus is diagnosed in small percent of patients suffering from gallstone disease, it accounts for a large proportion of intestine obstruction in patients older than 65 years old. Since accurate diagnosis and timely intervention are vital, providers should be familiar with the diagnostic approach and the treatment of this clinical entity.

Cholecysto-pyloric fistula with submucosal impaction of gall stone causing gastric outlet obstruction masquerading as a gastric mass, Bouveret Syndrome: case report

Background

Cholecysto-enteric fistula is a rare complication of cholelithiasis and cholecystitis. Another even rarer complication is proximal impaction of gallstone(s) in gastric pylorus leading to gastric outlet obstruction, known as the Bouveret Syndrome. Only a few cases have been reported in the available literature. It can be confused with a malignant thickening at the pylorus, knowledge of this syndrome helps in arriving at the right diagnosis.

Case report

A 52-year-old female patient, who was admitted to our hospital for evaluation of recurrent vomiting and abdominal pain. She was investigated with various imaging modalities including upper gastrointestinal (GI) endoscopy, abdominal ultrasonography as well as Contrast Enhanced Computerized Tomography (CECT) scan of the abdomen. On the outside scan, it was given as a malignant thickening at the pylorus. However, current radiologists felt that imaging findings were not of a typical malignant mass, and suspicion of Bouveret syndrome was given. Intraoperative findings confirmed the diagnosis of Bouveret syndrome. The patient has not experienced any postoperative complications till now.

Conclusion

Bouveret syndrome is associated with significant morbidity and mortality. Being familiar with the imaging appearance of this condition, and differentiating it with malignant thickening can help radiologists avoid unnecessary invasive procedures in such patients. Being a benign etiology, it also helps in a better prognosis.

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.

Gas in the Portal Vein: An Emergency or Just Hot Air?

We report the case of a 87-year-old woman admitted to our Emergency Department for mild abdominal pain associated with vomiting. An abdominal X-ray showed gas present in the portal venules of the left hepatic lobe, a finding associated with numerous surgical and medical conditions. The patient was successfully managed with conservative treatment. Isolated intrahepatic gas is a rare radiologic finding; emergency surgery should be performed only when there are signs of associated acute intestinal infarction.

Bouveret syndrome-a rare form of gastric outlet obstruction

Bouveret syndrome is a rare form of gastric outlet obstruction. It is typically diagnosed in frail elderly patients with protracted biliary disease. Thus, it has disproportionally high rates of morbidity and mortality. A 90-year-old man presented to our tertiary hospital with acute abdominal pain and symptoms of bowel obstruction. He was diagnosed with Bouveret syndrome on abdominal computed tomography and required judicious resuscitation and an emergency laparotomy. This article highlights the key features of Bouveret syndrome, and reviews the current diagnostic modalities as well as the contemporary treatment paradigm.

Bouveret syndrome: a rare cause of gastric outlet obstruction

Bouveret syndrome is a rare cause of gastric outlet obstruction. It is characterised by the presence of an obstructing gallstone in the pylorus or proximal duodenum, which has travelled to its obstructing position via an acquired fistula. Our case involves a 73-year-old man presenting to the acute surgical take with a 2-day history of right-sided abdominal pain and vomiting. His medical history included perforated cholecystitis treated with antibiotics and percutaneous gall bladder drainage, 1 year earlier. Examination and blood tests were suggestive of gastric outlet obstruction. CT abdomen and pelvis demonstrated a large gallstone obstructing the duodenum, confirming a diagnosis of Bouveret syndrome. The patient improved following gastrolithotomy, and was discharged 2 weeks postoperatively. Fistula formation is a complication of chronic cholecystitis and therefore Bouveret syndrome should be considered in patients with a background of gallstone disease presenting with gastric outlet obstruction.

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.

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.

Bouveret syndrome: A series of cases that illustrates a rare complication of chronic cholelithiasis

Bouveret syndrome is defined as gastric outlet obstruction secondary to the impaction of a large gallstone in the proximal gastrointestinal tract. The obstruction occurs as result of a bilio-enteric or bilio-gastric fistula. This clinical entity is a rare variant of the more commonly recognized gallstone ileus, which tends to cause small bowel obstruction of the terminal ileum. The typical presentation of Bouveret syndrome consists of nausea, vomiting and abdominal pain secondary to obstruction. Diagnosis often requires radiographic imaging with computed tomography, which typically shows pneumobilia or a cholecystoduodenal fistula. Herein is a series consisting of three cases of Bouveret syndrome involving a bilioenteric, cholecystoduodenal, and choledochoduodenal fistula, respectfully, all of which required operative management. A discussion of the current literature regarding management of this rare syndrome follows.

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.

Role of magnetic resonance imaging in Bouveret's syndrome: A case report with review of the literature

Bouveret's syndrome is a rare form of gallstone ileus occurring due to obstructing gallstone into the proximal duodenum through a cholecystoduodenal fistula. We report the case of a 72-year-old female presenting with abdominal pain secondary to a large gallstone in the region of the duodenal bulb, causing the upstream gastric obstruction. Here we discuss the clinical features, imaging technologies, and surgical management of Bouveret's syndrome.

Bouveret's syndrome: a strategic approach for management

An 81-year-old woman, diabetic and hypertensive, presented with nausea and intermittent vomiting. She had dysphagia and loss of appetite for over 6 weeks and significant weight loss over 3 weeks and was admitted in general surgery unit on emergency basis. Investigations revealed dilated stomach and a stone in first part of duodenum, with probable site of obstruction at level of first part of duodenum, secondary to a cholecystoduodenal fistula. With a preoperative diagnosis of Bouveret's syndrome, she underwent laparotomy and subtotal cholecystectomy. Postoperative recovery was delayed due to gastroparesis and delayed gastric emptying which resolved with conservative management. Successful management of this case required a multidisciplinary team approach. Early diagnosis was the key to management. Mode of treatment and management of Bouveret's syndrome should be tailored to suit patient's age, comorbidities and performance status.

Bouveret syndrome: a rare form of gallstone ileus

A 57-year-old woman presented with a 5-day history of worsening right upper quadrant pain, bilious emesis and approximately 20 pounds of weight loss. The patient was afebrile, without jaundice and had mild tenderness in her right upper quadrant. She noted an incidental finding of asymptomatic cholelithiasis on imaging 4 years earlier. An abdominal radiograph revealed pneumobilia and a large ectopic calculus. An abdominal CT scan confirmed pneumobilia, a large concretion completely obstructing the third portion of the duodenum and a soft tissue communication between the gallbladder and proximal duodenum. She was brought to the operating room for definitive treatment and had the obstructing gallstone removed via a transverse duodenotomy. Bouveret syndrome is a rare cause of small bowel obstruction that requires a high index of suspicion for diagnosis. It should be considered in older patients with clinical evidence of gastric or duodenal obstruction, particularly with a history of cholelithiasis.