1302 Bouveret's Syndrome: An Overlooked Cause of Duodenal Obstruction

Abstract

INTRODUCTION: Bouveret's syndrome is a rare clinical entity of gastric outlet obstruction from an impacted gallstone in the pyloric channel or duodenum. The stone travels from the biliary tree via a fistulous tract, formed in the setting of cholecystitis or pericholecystic inflammation. Diagnosis is typically made by computed tomography or magnetic resonance imaging, and treatment is focused on disimpaction via endoscopic, laparoscopic, or open intervention. We report a case of Bouveret's syndrome causing duodenal obstruction that was endoscopically managed with fusion lithotripsy basket extraction. CASE DESCRIPTION/METHODS: Patient is an 85 year-old male with a history of hypertension and coronary artery bypass grafting that presented with severe upper abdominal pain, vomiting, and melenic stools for three days. Vital signs were within normal limits. Laboratory data was significant for mild leukocytosis (11.7 thousand/mcl) and anemia (11.7 gm/dL; baseline 13 gm/dL). Abdominal ultrasound and computed tomography without contrast of the abdomen/pelvis revealed large gallstones, suspicious biliary air with intrahepatic ductal extension, superimposed gallbladder wall thickening suggestive of possible cholecystitis, and inflammatory changes extending to the distal stomach. Antibiotic therapy with piperacillin-tazobactam was initiated. Patient underwent esophagogastroduodenoscopy for evaluation of melena, which showed ulcerative esophagitis, erosive gastritis, and a large gallstone in the duodenal sweep with surrounding ulceration causing duodenal obstruction. Endoscopic lithotripsy with stone crushing basket was performed to fragment the large gallstone in smaller retractable pieces. For further evaluation, endoscopic retrograde cholangiopancreatography was performed and notable for a cholecystoduodenal fistula. Given his clinical state, the patient was not a surgical candidate during the hospitalization, but was recommended to follow up with general surgery outpatient. DISCUSSION: Bouveret's syndrome is commonly missed in clinical practice when it is not considered in the setting of intestinal obstruction, especially in males with no history of gallstone disease as seen in our patient. There are no formal management guidelines of this condition. However, endoscopic extraction with or without lithotripsy is preferable, particularly in cases when the patient is a poor candidate for surgical enterolithotomy. It is imperative to facilitate early diagnosis to improve prognosis and prevent adverse outcomes.