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Case Reports
. 2003 Dec;9(12):2873-5.
doi: 10.3748/wjg.v9.i12.2873.

Bouveret's syndrome complicated by a distal gallstone ileus

Rasim Gencosmanoglu  1 , Resit Inceoglu, Caglar Baysal, Sertac Akansel, Nurdan Tozun
Affiliations
Case Reports

Bouveret's syndrome complicated by a distal gallstone ileus

Rasim Gencosmanoglu et al. World J Gastroenterol. 2003 Dec.

Abstract

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

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

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

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

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Figures

Figure 1
Figure 1
Endoscopic appearance of a large duodenal stone (black arrows) causing complete obstruction. Note the irregu-lar edges of the stone (white arrows), which indicate its fragmentation.
Figure 2
Figure 2
CT shows: A: A large, 5×3×3 cm, intraluminal stone (arrow) in the proximal jejunum, B: Another stone in the duode-nal bulb (arrow).
Figure 3
Figure 3
Intraoperative views: A: The obstructed proximal jejunal segment, note a large intraluminal stone causing complete intestinal obstruction at this level, B: Removal of the stone with enterotomy, C: Macroscopic view of the fragmented gallstone which had a very hard outer shell with a soft core.
Figure 4
Figure 4
After the adhesions between the gallbladder (arrow) and the adjacent organs were dissected, cholecystoduodenal fistula (arrow head) was broken down and then the retained stone was removed.
Figure 5
Figure 5
Intraoperative ultrasound revealed that the suspicious stone was in the gallbladder instead of the duodenal lumen.
See this image and copyright information in PMC

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