Bouveret's Syndrome: An Overlooked Diagnosis. A Case Report and Review of Literature

Complex presentation of Bouveret syndrome: Gastric outlet obstruction and septic complications

Bouveret syndrome, a rare form of gastric outlet obstruction, occurs when a large gallstone migrates through a cholecystoenteric fistula into the duodenum, causing obstruction. We report a 31-year-old female who initially presented with nausea, vomiting, and abdominal pain. Imaging identified a large, calcified gallstone, a hepatic abscess, and acute cholecystitis. Initial treatment involved drainage of the hepatic abscess and antibiotics, with plans for elective cholecystectomy. Three years later, she returned with recurrent symptoms, including early satiety, significant weight loss, and gastric outlet obstruction. Endoscopy confirmed duodenal obstruction, and further imaging revealed a cholecystoduodenal fistula. She underwent an open cholecystectomy with fistula excision, duodenal repair, and nasojejunal feeding tube placement. Her postoperative recovery was smooth, with a gradual return to enteral nutrition. This report presents essential diagnostic and treatment approaches for Bouveret syndrome, including the roles of imaging, endoscopy, and surgery in managing complex cases. Early recognition and a coordinated, individualized treatment plan are crucial to optimizing outcomes in this rare condition.

Endoscopic Treatment of Bouveret Syndrome with Combined Laser and Mechanical Lithotripsy: A Case Report

Background: Bouveret syndrome is a complication of cholelithiasis, characterized by the migration of a large gallstone from the gallbladder to a part of the stomach or intestine through a bilio-enteric fistula. This condition results in a rare form of gallstone ileus, presenting signs and symptoms of gastric outlet obstruction. Methods: This case report aims to present a rare instance of Bouveret syndrome in a 64-year-old woman who presented to our emergency department with recurrent epigastric pain and vomiting for over 2 months. After a CT scan, an esophagogastroscopy was performed following a multidisciplinary discussion. An endoscopic evaluation revealed a large (4 cm) gallstone found in the proximal duodenum using an endoscope. We then inserted the holmium laser fiber system through a standard ERCP catheter, passing it through the endoscope's working channel. By positioning the holmium laser fiber within the catheter, we stabilized the energy on the gallstone, which was then fragmented into smaller pieces after administering pulse energy. Results: In this case report, we successfully treated Bouveret syndrome using endoscopic laser lithotripsy combined with mechanical lithotripsy, avoiding traditional surgery. Conclusions: The endoscopic approach that combines laser and mechanical lithotripsy appears effective in fragmenting large gallstones into smaller pieces, facilitating their passage through the digestive tract and resolving the obstruction.

A pictorial essay on cross-sectional imaging findings of pathologies in the second (D2) segment of the duodenum in adults

The duodenum, the initial segment of the small intestine, is divided into four parts: the superior (D1), descending (second) (D2), horizontal (D3), and ascending (D4) segments. Despite its short length, the descending part (D2 segment) holds clinical significance due to its anatomical proximity to structures such as the gallbladder, right kidney, colon, and pancreas. This anatomical localization and contiguity give rise to various pathologies, including congenital, inflammatory, infectious, neoplastic, vascular, and traumatic conditions. Cross-sectional imaging modalities play a pivotal role in evaluating pathologies of the second (D2) segment of the duodenum. This article aims to provide a comprehensive overview of these pathologies and delineate their imaging characteristics.

Bouveret Syndrome: A Rare Cause of Gastric Outlet Obstruction and Treatment Options

Bouveret syndrome is an uncommon condition that leads to gastric outlet obstruction. Diagnosis and treatment may get delayed due to non-specific presentation and rarity of the condition, which is associated with high morbidity and mortality. We present a case of a 62-year-old female who presented with epigastric pain and nausea and was diagnosed with Bouveret syndrome. Despite the low success rate, endoscopy should be the first-line diagnostic and therapeutic procedure and is associated with a low mortality rate as compared to surgical intervention. This case underscores the diagnostic and therapeutic challenges of Bouveret syndrome.

Bouveret's Syndrome Presenting as Jejunal Obstruction: A Case Report

Bouveret's syndrome, a rare and severe complication of gallstone disease, is characterized by gastric outlet obstruction resulting from the passage of a gallstone through a bilioenteric fistula, typically a cholecystoduodenal fistula. We present the case of a 68-year-old female patient with bilateral low back pain, nausea, vomiting, and constipation. Imaging revealed jejunal obstruction due to gallstone migration through a cholecystoduodenal fistula. Initial management involved nasogastric decompression and fluid resuscitation, followed by enterolithotomy. Diagnosis of Bouveret's syndrome is challenging due to nonspecific symptoms. Imaging, particularly computed tomography (CT), is essential for identifying Rigler's triad: pneumobilia, bowel obstruction, and ectopic gallstone. Early intervention is essential to avoid complications. This case highlights the complexity of diagnosing and managing Bouveret's syndrome. A high degree of clinical suspicion is essential for accurate diagnosis and timely treatment, ensuring the optimal management of Bouveret's syndrome.

Gastroduodenal Obstruction Due to Bouveret's Syndrome: A Case Report

Bouveret's syndrome is a rare disorder that causes upper gastrointestinal obstruction, typically in elderly patients with a history of chronic cholelithiasis. We present an unusual case of a 58-year-old woman with untreated vesicular lithiasis who developed Bouveret's syndrome. She presented with severe abdominal pain, nausea, vomiting, and abdominal distension. Imaging studies confirmed the presence of an impacted gallstone in the duodenum, causing obstruction. The patient underwent successful surgery with removal of the stone and repair of the bilioenteric fistula. Early diagnosis and prompt surgical intervention are essential to prevent complications such as bowel perforation and sepsis. This case highlights the importance of considering Bouveret's syndrome in the differential diagnosis of bowel obstruction, particularly in elderly patients with a history of cholelithiasis.

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.

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.

Gastric Outlet Obstruction Caused by Complicated Cholelithiasis: Bouveret Syndrome

Teaching Point: Bouveret syndrome can be diagnosed on plain film, ultrasound, computed tomography and magnetic resonance imaging by demonstrating Rigler's triad which includes a dilated stomach, pneumobilia, and ectopic gallstone.

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.

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.

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.

Two unique cases of Bouveret syndrome with review of literature

Bouveret syndrome is a rare form of gallstone ileus in which a proximally lodged gallstone in the duodenum causes a gastric outlet obstruction. It is a rare condition that can be challenging to manage. Although endoscopic management remains first line, a surgical approach can be needed. We present two cases of Bouveret syndrome. A 65-year-old man with oral squamous cell carcinoma treated with endoscopic management and a 63-year-old woman treated with surgery.

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.

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.

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.

Upper Gastrointestinal Bleeding: A Potential Precursor to Bouveret's Syndrome

Bouveret's syndrome is a rare complication of cholelithiasis. It is characterized by a gallstone entering the intestine through a cholecystoenteric fistula, impacting the duodenum and causing gastric outlet obstruction. Rarely, it presents with hematemesis and melena. The diagnosis involves computed tomography (CT) and the treatment depends on the patient's stability, the location of the obstruction, stone size, and the fistula. Endoscopy or minimally invasive lithotripsy can be considered initially. If this fails, surgical intervention is recommended. We present a case of upper gastrointestinal bleeding (UGIB) preceding the development of Bouveret's syndrome.

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.

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 clinicoradiological perspective

An 87-year-old woman presented to us with a 5-day history of worsening epigastric pain and vomiting. Her medical history included known gallstones and a previous episode of acute cholecystitis complicated by a perforated gallbladder for which she had declined surgery 5 years prior. Radiological imaging confirmed a large gallstone impacted in the first part of the duodenum with gross gastric outlet obstruction and pneumobilia, confirming the diagnosis of Bouveret syndrome, an often overlooked and rare variant of gallstone ileus. Following an unsuccessful oesophagogastroduodenoscopy for stone retrieval, she underwent a laparotomy and gastrotomy with a successful outcome and discharged from hospital 4 weeks following the procedure.

Bouveret Syndrome: A Rare Case of Gallstone Ileus Further Complicated by Stone Migration

Bouveret syndrome is a rare cause of gastric outlet obstruction due to gallstone impaction in the pylorus or proximal duodenum. This paper reports a case of Bouveret syndrome in a 66-year-old male patient in whom pre-operative investigations revealed a gallstone within the distal stomach, but spontaneous migration of the stone resulted in intraoperative difficulty requiring further surgical exploration than originally anticipated.

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.

Bouveret's syndrome as a rare complication of cholelithiasis: Disputes in current management and report of two cases

INTRODUCTION

Bouveret's syndrome is a rare complication of cholelithiasis that determines an unusual type of gallstone ileus, secondary to an acquired fistula between the gallbladder and either the duodenum or stomach with impaction of a large gallbladder stone. Preoperative diagnosis is difficult because of its rarity and the absence of typical symptoms. Adequate treatment consists of endoscopic or surgical removal of obstructive stone.

PRESENTATION OF CASES

Two old females patients were admitted to the Emergency Department with a history of abdominal pain associated with bilious vomiting. Physical examination revealed abdominal distension with tympanic percussion of the upper quadrants, abdominal pain on deep palpation of all quadrants and in the first patient positive Murphy's sign. Preoperative diagnosis of gallstone impacted in the duodenum was obtained by abdominal computed tomography (CT) scan in the first patient and by esophagogastroduodenoscopy in the second one. Both patients underwent surgery with extraction of the gallstone from the stomach. Postoperative course of two patients was uneventful and they were discharged home.

DISCUSSION

Bouveret's syndrome usually presents with signs and symptoms of gastric outlet obstruction. Preoperative radiological investigations not always are useful for its diagnosis. Appropriate treatment, endoscopic or surgical, is debated and must be tailored to each patient considering medical condition, age and comorbidities.

CONCLUSION

Bouveret's syndrome is a very rare complication of cholelithiasis, difficult to diagnose and suspect, because of lack of pathognomonic symptoms. Nowaday there are no guidelines for the correct management of this pathology. Endoscopic or surgical removal of obstructive stone represents the correct treatment.

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 and cholecystogastric fistula: a case-report and review of the literature

An exceptionally rare cause of gastric outlet obstruction, Bouveret's syndrome results from proximal impaction of an ectopic gallstone, enabled by fistulization that aberrantly connects the biliary and luminal gastrointestinal tract, typically a cholecystoduodenal fistula. It occurs with a 2:1 female predominance, most often in the eighth decade of life. Endoscopic treatment is the preferred first-line strategy in management, followed by surgical intervention if unsuccessful. Endoscopy failed to retrieve the stone due to its size, despite attempted lithotripsy, which prompted laparoscopic retrieval. Bouveret's syndrome compels a high index of suspicion in proximal gastrointestinal obstruction even when presenting in a male a decade younger than the median age of diagnosis (74 years), with no preceding biliary symptoms particularly as early intervention can considerably reduce morbidity and mortality.

A case report and review of the literature of Bouveret syndrome

Bouveret syndrome is a rare variant of gallstone ileus causing gastric outlet obstruction. It results from the formation of either a cholecystoduodenal or a cholecystogastric fistula and subsequent migration of gallstone into the duodenum or pylorus of stomach, causing obstruction. The first case was reported by Leon Bouveret in 1896. We report a case illustrating the rarity and severity of this condition, together with a review of the literature of the different methods of endoscopic and surgical treatment.

Successful Treatment of Bouveret Syndrome by Electrohydraulic Lithotripsy and Double Balloon Endoscopy

Patient: Female, 84

Final Diagnosis: Bouveret syndrome

Symptoms: Abdominal and/or epigastric pain vomitting

Medication: —

Clinical Procedure: Electrohydraulic lithotripsy

Specialty: Gastroenterology and Hepatology

Bouveret's Syndrome

Bouveret syndrome is a very rare form of gastric outlet obstruction following the passage of a gallstone from the gallbladder to the duodenum or pylorus through a bilioenteric fistula. We present a unique case of a 78-year-old male complaining of right upper quadrant abdominal pain and who was found to have a gallstone in the proximal duodenum along with pneumobilia and cholecysto-duodenal fistula suggestive of Bouveret’s syndrome.

Rare cause of gastric outlet obstruction

Bouveret’s syndrome is a rare cause of gastric outlet obstruction. The stones enter the small bowel via cholecysto-enteric fistula. The most common presenting symptoms are abdominal pain, nausea and vomiting. The gold standard diagnostic test isesophagogastroduodenoscopy (EGD). Rigler’s triad on abdominal x-ray is classic. CT scan findings are pneumobilia, cholecystoduodenal fistula and a gallstone in the duodenum. We present a case of a 75-year-old female who presents with 3 week history of nausea, vomiting, and diffuse abdominal pain. Initial presentation, imaging and EGD was concerning for malignancy. She was later diagnosed to have Bouveret’s syndrome and underwent laparoscopic small bowel enterotomy with removal of gallstones

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.

Gallstone ileus of the duodenum: an unexpected presentation of Bouveret's syndrome

This report describes a patient who presented with a large gallstone obstructing the duodenal bulb, with the chief complaint of acute on chronic abdominal pain. Classically, this is known as Bouveret's syndrome or a gallstone ileus of the duodenum. Our patient's current health status presented a challenge, with the presence of several comorbidities, particularly a large abdominal aortic aneurism. We chose an open procedure for this reason. The stone was removed through a laparotomy, and the cholecystoduodenal fistula that the stone used to pass into the small bowel was repaired. With our patient's future medical needs in mind, only the necessary interventions were performed to regain functionality of the bowel. This came in the form of a diverting gastrojejunostomy, with a distal jejunostomy and feeding tube inserted. The patient tolerated the procedure well, only remaining intubated postoperative due to her chronic obstructive pulmonary disease (COPD). She achieved a complete recovery and transitioned home.

Less is more: an outcome assessment of patients operated for gallstone ileus without fistula treatment

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In this study, 1.9% patients were diagnosed with gallstone ileus among those admitted for small bowel obstruction.

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85% of them underwent a conservative surgical approach mainly consisting in the enterolithotomy.

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Only one complication exceeded grade II in each group and no deaths were reported.

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Mean follow-up was 50 months and only one patient without fistula treatment had recurrent disease; no gallbladder cancer were identified.

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Enterolithotomy without fistula closure proved to be safe and effective for the management of gallstone ileus both on a short and long-term basis.

Background

The treatment of gallstone ileus (GI) consists of surgical removal of the impacted bilestone with or without cholecystectomy and repair of the biliodigestive fistula. The objective of this study was to assess whether sparing patients a definitive biliary procedure adversely influenced the outcome.

Materials and methods

Patients with a diagnosis of GI were reviewed. Two groups were identified: patients who underwent a definitive biliary procedure with relieving the intestinal obstruction (group 1/G1) and those who did not have a definitive biliary procedure (group 2/G2). In G2, patients were evaluated on long-term follow-up for the risk of recurrent GI disease, cholecystitis, cholangitis and gallbladder cancer.

Results

Among 1075 patients admitted for small bowel obstruction, 20 (1.9%) were diagnosed with gallstone ileus. 3 (15%) of these belong to G1, 17 (85%) to G2. The overall postoperative morbidity rate was 35% (7/20) with one complication exceeding grade II in each group. No deaths were reported. Mean follow-up was 50 months. During follow-up, one of G2 patients had recurrent disease. No biliary tract infections or gallbladder cancer were identified.

Conclusion

Enterolithotomy without fistula closure is confirmed to be safe and effective for the management of gallstone ileus both on a short- and long-term basis.

Uncommon presentation of a common disease - Bouveret's syndrome: A case report and systematic literature review

AIM

To investigate and summarise the current evidence surrounding management of Bouveret's syndrome (BS).

METHODS

A MEDLINE search was performed for the BS. The search was conducted independently by two clinicians (Yahya AL-Habbal and Matthew Ng) in April 2016. A case of BS is also described.

RESULTS

A total of 315 articles, published from 1967 to 2016, were found. For a clinically meaningful clinical review, articles published before 01/01/1990 and were excluded, leaving 235 unique articles to review. Twenty-seven articles were not available (neither by direct communication nor through inter-library transfer). These were also excluded. The final number of articles reviewed was 208. There were 161 case reports, 13 reviews, 23 images (radiological and clinical images), and 11 letters to editor. Female to male ratio was 1.82. Mean age was 74 years. Treatment modalities included laparotomy in the majority of cases, laparoscopic surgery, endoscopic surgery and shockwave lithotripsy.

CONCLUSION

There is limited evidence in the literature about the appropriate approach. We suggest an algorithm for management of BS.

Bowel obstruction and perforation due to a large gallstone. A case report

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Gallstone obstruction is a rare clinical entity presenting usually in elderly patients and is associated with a medical history of biliary symptoms.

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CT examination uncovered all findings consisting Rigler’s triad, thus air in the gall bladder, bowel obstruction and a gallstone inside the bowel lumen. It also identified a cholecystoduodenal fistula.

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Rupture of the small bowel occurred intraoperatively, and a large 3.2 cm gallstone was located in the terminal ileum, which was recovered.

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Post-surgical recovery was uneventful with no further report of obstruction symptoms at 6 month follow up.

Introduction

Gallstone bowel obstruction is a rare form of mechanical ileus usually presenting in elderly patients, and is associated with chronic or acute cholecystitis episodes.

Case presentation

We present the case of an 80 year old female with abdominal pain, inability to defecate and recurrent episodes of diarrhea for the past 8 months. CT examination uncovered a cholecystoduodenal fistula along with gas in the gall bladder and the presence of a ≥2 cm gallstone inside the small bowel lumen causing obstruction. Patient was admitted to the operating room, where a 3.2 cm gallstone was located in the terminal ileus. A rupture was found in the antimesenteric part of a discolored small bowel segment, approximately 60 cm from the ileocaecal valve, through which the gallstone was recovered. The bowel regained its peristalsis, and the rupture was debrided and sutured. Patient was discharged uneventfully on the 6th postoperative day.

Discussion

Gallstone ileus is caused due to the impaction of a gallstone inside the bowel lumen. It usually passes through a fistula connecting the gallstone with the gastrointestinal tract. It can present with nonspecific or acute abdominal symptoms. CT usually confirms the diagnosis, while there are a number of treatment options; conservative, minimal invasive and surgical. Our patient was successfully relieved of the obstruction through recovery of the gallstone using open surgery, with no repair of the fistula.

Conclussion

Although rare, gallstones must be suspected as a possible cause of bowel obstruction, especially in elderly patients reporting biliary symptoms.

Gallstone ileus with choledochoduodenal fistulas: A case report and literature review

Gallstone ileus (GI) with choledochoduodenal fistulas and multiple sites of intestinal obstruction are uncommon. Early diagnosis and appropriate surgery are crucial to reduce morbidity and mortality of GI. Computed tomography plays an important role in making early, accurate diagnosis, and laparoscopy-assisted surgery is helpful to optimizing surgical treatment and early recovery. This paper presents such a case and performed a literature review to improve the awareness of the approach for the management of GI.