Bouveret's syndrome: A rare presentation of gallstone disease

Srinivas Kavuturu; Vellore Parithivel; John Cosgrove

doi:10.4103/IJAM.IJAM_83_16

CASE REPORTS: REPUBLICATION

Year : 2017 | Volume : 3 | Issue : 3 | Page : 173-175

Bouveret's syndrome: A rare presentation of gallstone disease

Srinivas Kavuturu, Vellore Parithivel, John Cosgrove
Department of Surgery, Bronx Lebanon Hospital Center, Bronx, NY, USA

Date of Web Publication

21-Apr-2017

Correspondence Address:
Srinivas Kavuturu
Department of Surgery, Bronx Lebanon Hospital Center, Bronx, NY
USA

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/IJAM.IJAM_83_16

Abstract

Biliary-enteric fistula is a rare complication of gallstone disease, and gallstone ileus is relatively a rare cause of intestinal obstruction. Most commonly, the stone lodges in the distal ileum, colon, or duodenum. The least common site of obstruction is the proximal duodenum or pylorus causing gastric outlet obstruction (Bouveret's syndrome). Presenting signs and symptoms of Bouveret's syndrome include nausea, vomiting, epigastric pain, and abdominal distension. Obstructive jaundice, gastrointestinal hemorrhage with or without hematemesis, pancreatitis, and duodenal perforation are less common. Abdominal radiography may show air in the biliary tree, mechanical bowel obstruction, and radio-opaque gallstone suggesting the diagnosis. Abdominal ultrasound or computerized tomography is diagnostic in about 60% of cases. In most cases, the treatment of Bouveret's syndrome is surgical. Surgical options include (a) a single-staged enterolithotomy (or gastrostomy) with concomitant cholecystectomy and repair of the fistula or (b) an enterolithotomy alone with or without a second-stage cholecystectomy. Endoscopic extraction of the stone has been described in selected patients. Lithotripsy techniques have also been successfully used to fragment large stones. The authors present a case of Bouveret's syndrome as well as a brief literature review of this topic.
The following core competencies are addressed in this article: Medical knowledge and patient care.
Republished with permission from: Kavuturu S, Parithivel V, Cosgrove J. Bouveret's syndrome: A rare presentation of gallstone disease. OPUS 12 Scientist 2008;2(2):11-12.

Keywords: Bouveret's syndrome, diagnosis and management, endoscopy, gallstone disease, lithotripsy, operative treatment

How to cite this article:
Kavuturu S, Parithivel V, Cosgrove J. Bouveret's syndrome: A rare presentation of gallstone disease. Int J Acad Med 2017;3, Suppl S1:173-5

How to cite this URL:
Kavuturu S, Parithivel V, Cosgrove J. Bouveret's syndrome: A rare presentation of gallstone disease. Int J Acad Med [serial online] 2017 [cited 2023 Mar 20];3, Suppl S1:173-5. Available from: https://www.ijam-web.org/text.asp?2017/3/3/173/204965

Introduction

Case Report

A 60-year-old woman presented to the emergency department with a history of acute abdominal pain, nausea, and vomiting of 48 h duration. The pain was localized to the epigastrium and right upper quadrant. Her medical history was significant for diabetes, hypertension, and asthma. She reported no history of any surgical procedure in the past.

Physical examination showed no jaundice. The patient had a distended abdomen with mild tenderness in the epigastric region but no peritoneal signs. Laboratory evaluation showed normal hepatic transaminases, normal bilirubin, and normal white blood cell count. Computed tomographic scan of the abdomen revealed air in the intra- and extra-hepatic biliary ducts, distended stomach, and a 2-cm gallstone with characteristic eggshell-like calcification within the first part of the duodenum [Figure 1]. The patient was treated with intravenous hydration and nasogastric suctioning.

Figure 1: Computed tomography showing a 2-cm gallstone with characteristic eggshell-like calcification within the first part of the duodenum

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After 3 days of nonoperative therapy, computed tomography of the abdomen was repeated, showing that the stone migrated into the terminal ileum. Due to lack of clinical improvement, the patient underwent a laparotomy and successful removal of the gallstone through an enterotomy. She was discharged home on the 5^th postoperative day, with plans for elective treatment of the cholecystoenteric fistula at a later date. She was doing well at the 6-week follow-up.

Discussion

Biliary-enteric fistula is a rare complication of gallstone disease (0.3%–0.5%), and gallstone ileus is relatively a rare cause of intestinal obstruction (3%). Most commonly, the stone lodges in the distal ileum (90%), colon (3%–8%), or duodenum (3%). The least common site of obstruction is the proximal duodenum or pylorus causing gastric outlet obstruction, which is known as Bouveret's syndrome.^[1] The condition's presenting clinical signs and symptoms usually include nausea, vomiting, epigastric pain, and abdominal distension. Obstructive jaundice, gastrointestinal hemorrhage with or without hematemesis, pancreatitis, and duodenal perforation are less common but well-known characteristics of the syndrome.^[1]

Plain X-ray abdomen may show air in the biliary tree, mechanical bowel obstruction, and radio-opaque gallstone suggesting the diagnosis.^[2],[3] In a study of 128 cases, endoscopy revealed gastroduodenal obstruction in nearly all cases but identified the obstructing stone in only 69% of cases. Abdominal ultrasound or computerized tomography was diagnostic in about 60% of cases.^[4]

In most cases, the treatment of Bouveret's syndrome is surgical. The surgical options include (a) a single-staged enterolithotomy (or gastrostomy) with concomitant cholecystectomy and repair of the fistula or (b) an enterolithotomy alone with or without a second-stage cholecystectomy. Endoscopic extraction of the stone is described in selected patients, in whom it is technically possible to dislodge and engage the stone in a dormia basket.^[5],[6] Extracorporeal shockwave lithotripsy,^[7] electrohydraulic lithotripsy,^[8] and laser lithotripsy ^[9] have also been successfully used to fragment large stones.

Conclusions

The authors present a case of Bouveret's syndrome in a 60-year-old woman. The diagnosis should be considered in patients with symptoms of gastric outlet obstruction with or without history of gallstones or aerobilia. Abdominal ultrasound or computerized tomography is diagnostic in about 60% of cases. In most cases, the treatment is surgical. Endoscopic treatment should be considered especially in high-risk patients.

Acknowledgement

Justifications for re-publishing this scholarly content include: (a) The phasing out of the original publication after a formal merger of OPUS 12 Scientist with the International Journal of Academic Medicine and (b) Wider dissemination of the research outcome(s) and the associated scientific knowledge.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

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