Bouveret's syndrome as an unusual cause of gastric outlet obstruction: a case report
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An 83 year old caucasian gentleman presented with vomiting and left sided abdominal pain. A subsequent upper GI endoscopy demonstrated a large smooth mass impacted within the duodenum. A cholecysto-duodenal fistula was discovered at laparotomy, with a large gallstone impacted in the duodenum. A diagnosis of Bouveret's syndrome was made. The management of this rare cause of gastric outlet obstruction is discussed.
KeywordsGastric Outlet Obstruction Fistula Repair Gallstone Ileus Quadrant Abdominal Pain Plain Abdominal Film
Gallstones, in the majority of patients remain asymptomatic. The commonest clinical manifestation is biliary colic. Gallstone ileus occurs when a stone enters the intestinal tract via a cholecysto-enteric fistula. The authors present a case of Bouveret's syndrome, a rare complication of gallstone disease and rare cause of gastric outlet obstruction.
Gallstone ileus is rare . The majority of gallstones that enter the GI tract via a cholecysto-enteric fistula are passed spontaneously. Obstruction most commonly occurs in the terminal ileum (90%) and less often in the duodenum (3%) . The differential diagnosis of gastric outlet obstruction includes diverticulae, foreign bodies, fibrotic ulcers and neoplasia Gastric outlet obstruction secondary to an impacted gallstone in the pyloric region or duodenal bulb is known as Bouveret's syndrome. More common in elderly women, Bouveret's syndrome presents with a non specific triad of epigastric pain, nausea and vomiting. Abdominal and chest radiographs should be performed looking for evidence of aerobilia, bowel obstruction and ectopic gallstones. Abdominal CT should also be performed. Typical findings on OGD include a dilated stomach and a hard non-fleshy mass at the obstruction .
Treatment options include endoscopic and surgical management. Endoscopic removal should always be attempted first, but lithotripsy and stone extraction is rarely successful . Intracorporeal endoscopic electrohydraulic lithotripsy has been used successfully in the treatment of Bouveret's syndrome  Surgical options include enterotomy and removal of the stones (enterolithotomy), enterolithotomy plus cholecystectomy and repair of the fistula, or gastric bypass surgery. The decision to use minimal invasive surgery versus laparotomy should be made on an individual patient basis and operator experience. Fistula repair is unnecessary due to spontaneous closure especially if the cystic duct is patent and no residual stones are present. Post operative mortality rates are high, and may reflect the older subgroup of patients affected .
The authors present a case of Bouveret's syndrome in an 83 year old gentleman. The diagnosis should be considered in patients with symptoms of gastric outlet obstruction with or without a history of gallstones or aerobilia and typical endoscopic findings of a dilated stomach and a hard non-fleshy mass at the obstruction.
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