2193 Role of Endoscopy in Bouveret Syndrome

Abstract

INTRODUCTION: Biliodigestive fistula is a rare complication of cholelithiasis which can lead to gallstone ileus. The gallstone after passing into GI tract is eliminated in 85 % of the cases through the feces or vomitus. However in 15 % of the cases it gets entrapped in the GI tract most commonly in the terminal ileum. We describe a case of an elderly patient who presented with Bouveret syndrome secondary to impaction of the biliary calculus in the first part of duodenum. CASE DESCRIPTION/METHODS: A 91 yo M presented to the hospital with one week history of nausea, vomiting and abdominal pain. He was noted to have right upper quadrant abdominal tenderness. Liver function tests were unremarkable. CT abdomen with oral contrast showed findings concerning for gastric outlet obstruction secondary to large lamellated gallstone along with a choledochoduodenal fistula. An upper GI endoscopy was done which showed a large immobile gallstone obstructing the first part of duodenum. An attempt to remove the stone endoscopically by various techniques including mechanical lithotripsy and net extraction was unsuccessful. A 7 cm gallstone partially contained in the gallbladder and extending to the duodenum was then successfully removed by open partial cholecystectomy with duodenal extraction followed by choledochoduodenal fistula repair. Patient recovered well without any complications after the surgery. DISCUSSION: Gallstone impaction in the duodenum and pylorus is extremely rare and can lead to gastric outlet obstruction, a condition known as Bouveret syndrome. Bouveret syndrome needs to be managed in a timely fashion. Clinically patients with this condition present with nausea, vomiting and abdominal pain. History of recent bouts of jaundice and biliary colic is seen in up to 70% of the patients. Rarely patients can present with hematemesis secondary to duodenal or celiac artery erosion. CT abdomen with contrast is the imaging of choice. Medium sized mobile stone in the duodenum can be successfully managed endoscopically by lithotripsy or net extraction. However when there is an immobile large calculus, endoscopy often fails and surgical extraction of the stone needs to be done to relieve the obstruction. Nevertheless considering the higher mortality associated with surgery, endoscopic removal of the calculus should be attempted first.