Unusual Presentation of Bouveret Syndrome Resulting in Both Gastric Outlet Obstruction and Small Bowel Obstruction with Perforation

Abstract

Our case describes an 83-year-old female who presented with severe abdominal pain, nausea, and bilious emesis of one day’s duration. She had an endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and percutaneous transhepatic biliary drainage (PTCD) one year prior for choledocholithiasis with acute cholangitis in her home country, Scotland. Unfortunately, while visiting family in the United States, her PTCD became dislodged, and she developed progressive worsening abdominal pain. Computerized tomography of her abdomen showed pneumobilia, perigastric inflammation, a contracted gallbladder, small bowl inflammation with a likely transition point at the mid-jejunum, and a probable duodenal mass. The patient underwent an exploratory laparotomy with intraoperative findings of choledochoduodenal fistula with coincident gastric and small bowel obstruction (SBO) secondary to three large, mixed gallstones. One 3 cm gallstone was located at the pylorus and two (2.3 and 3 cm) gallstones were isolated in the mid-jejunum, with one of those causing isolated transmural pressure necrosis with subsequent perforation. Bouveret syndrome is a rare cause of gastric outlet obstruction (GOO) that manifests via an acquired cholecystoenteric fistula. Our patient presented with a concomitant GOO and SBO with perforation of the mid-jejunum. Timely diagnosis of Bouveret syndrome is essential, as most causes require emergent surgical intervention.

Two Sites of Obstruction with Gallstones: A Case Report of Bouveret Syndrome with a Concurrent Biliary Ileus

“…Concerning the stone in the jejunum, it certainly moved more distally while awaiting surgery, and such movement was previously reported to occur [6,12,14,19]. The standard management of the gallstone ileus is enterolithotomy and stone extraction [2-5, 15, 19, 20], or with resection of irreversibly damaged parts of the small bowel [4,7,8,15,20], as in the present case. The stone in the duodenum of our patient has been managed following standard procedures with the extraction of the stone through a gastrotomy [1,13,17].…”

“…Multiple stones may be retrieved in the digestive tract [5][6][7], but recurrence is uncommon [2,3,8]. Nevertheless, simultaneous dual-site obstruction is very rare [9][10][11][12], with only two earlier reported cases involving Bouveret syndrome in the literature [7,13]. In the present report, we describe an interesting case of Bouveret syndrome causing gastric outlet obstruction with a simultaneous obstructive gallstone in the jejunum.…”

“…However, 25% of intestinal obstructions in patients older than 65 years are attributable to gallstones [2,3,8,14,15]. Multiple stones may be retrieved in the digestive tract [5][6][7], and recurrence is reported between 2% and 8% [2,3,8]. Nearly, half of the episodes of recurrence occur within one month [2,3,6], and recurrence in the immediate postoperative period has also been reported [4,8,[14][15][16].…”

“…Only two cases involving Bouveret syndrome associated with concurrent obstructive gallstones along the digestive were reported earlier in the literature [7,13], with the first one in the sigmoid part of the colon [13] and the second one in the jejunum [7]. During surgical exploration, it is of major importance to palpate the digestive tract to rule out missed gallstones that could cause subsequent intestinal obstruction [2,5,8,[10][11][12], since stones can be multiple [6,7,[9][10][11][12][13]21], migrate [8,14,19,22], or be unidentified on imaging [21,23,24]. Even though CT scan has a better diagnostic yield than plain abdominal X-ray [1,21,24] with a sensitivity of 93% [21,23], it certainly cannot be a substitute for a thorough inspection of the bowel, that is, an essential part, of the treatment of gallstone ileus [2].…”

“…Biliary ileus, also known as gallstone ileus, refers to an impacted gallstone within the lumen of the bowel causing obstruction [2][3][4]. Multiple stones may be retrieved in the digestive tract [5][6][7], but recurrence is uncommon [2,3,8]. Nevertheless, simultaneous dual-site obstruction is very rare [9][10][11][12], with only two earlier reported cases involving Bouveret syndrome in the literature [7,13].…”