Case report - Bouveret's syndrome with pancreatitis: A rare combination

Abstract

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.

Keywords: Bouveret’s syndrome; Case report; Cholecystoduodenal fistula; Gallstone ileus; Gastric outlet obstruction; Pancreatitis.

Fig. 1

Showing 4.2 cm calcified gallstone within the duodenum on CT abdomen.

Fig. 2

Showing the formed fistula tract between gallbladder and duodenum by the large gallstone on CT abdomen.

Fig. 3

Showing the gallstone in duodenum visualized using endoscopy.

Fig. 4

Showing series of endoscopic tools used to retrieve the gallstone.