Bouveret Syndrome in an Elderly Female

Abstract

Introduction: A gastric outlet obstruction secondary to a gallstone ileus is known as Bouveret syndrome. Herein we present a case of an elderly woman with an impacted gallstone in duodenum and discuss its' management. Patient description:A 96-year-old woman was admitted to our department due to a gastric outlet obstruction. Initial gastroscopy revealed a gastric bezoar. An attempt for its extraction failed. She underwent a laparotomy in which a cholecystoduodenal fi stula and a large impacted stone were found. Separation of the fi stula, including closure of the duodenum side, cholecystectomy and removal of the obstructing gallstone were performed. Additional stones were found and retrieved during common bile duct (CBD) exploration. Surgery was fi nalized by duodenoplasty, closure and T-tube drainage of the CBD. Post-operative course was prolonged and uneventful. Discussion and Conclusions:Bouveret syndrome is a rare cause of gastric outlet obstructions. In this case, unsuccessful endoscopic treatment necessitated surgery for removal of impacted gallstone in the duodenum.

The curious case of biliary emesis and bowel obstruction from Bouveret syndrome

“…Bilious vomiting is uncommon in Bouveret syndrome, especially with the former being reported in only four case reports 5 10–13. Bilious emesis suggests that the level of the obstruction lies distal to either the ampulla of Vater or the cholecystoduodenal fistula opening in the duodenum, which should be the latter in this case.…”

Bouveret Syndrome Resolved by a Two-Staged Endoscopic and Surgical Approach

“…The ideal is to have different equipment such as baskets, forceps, biliary balloons, laser lithotripsy, extracorporeal lithotripsy, or intracorporeal electrohydraulic lithotripsy, or the combination of these to offer different therapeutic procedures [3,17,18]. However, by means of endoscopy in Bouveret's syndrome, at the moment, it does not correct the existing fistula, in addition, it is not possible to assess the existence of stones distally coupled with the high probability of failure since much experience is needed from the specialist to obtain good results.…”

“…About 42% of patients in whom endoscopic stone removal is attempted, end up in surgical management. The current treatment of choice for biliary ileus is enterolithotomy combined with exploratory laparotomy to assess the duodenum and small intestine and colon [1,[8][9][10][11]18,19].…”

“…In unstable patients, delayed cholecystectomy is performed being the preferred behavior in most cases [20], since the combination of the two procedures in one surgery is reflected in increased mortality of up to 35%; however, when the fistula remains, it favors the recurrence of the biliary ileus or the appearance of cancer with a frequency of up to 15%. [8,9,12,14,15,[18][19][20].…”