2584 Running Into a Stone Wall: A Rare Case of Gastric Outlet Obstruction

Abstract

INTRODUCTION: Bouveret syndrome is an extremely rare and serious form of gallstone ileus with an incidence of 1-3% and a surgical mortality rate approaching 15-33 percent. Treatment often involves a combination of endoscopic and surgical interventions. We present a case of gastric outlet obstruction and duodenal ulceration caused by 3 impacted gallstones, treated ultimately with surgery. CASE DESCRIPTION/METHODS: A 57-year-old male with no known medical conditions was admitted to the intensive care unit with a one-week history of epigastric pain, nausea, and dark emesis. He was tachycardic and hypotensive on arrival. On exam, the patient was diaphoretic with dark-bloody return from the nasogastric tube. Hemoglobin was 5.6 g/dL (ref: 14.0-16.8 g/dL) with a leukocytosis of 17.69 K/uL (ref: 4.0-10.8 K/uL). Liver enzymes were unremarkable. Given concerns for an upper gastrointestinal bleed, patient underwent an esophagogastroduodenoscopy showing a 3-cm non-bleeding ulcer in the duodenal bulb, a cholecystoduodenal fistula, and a large impacted gallstone in the first portion of the duodenum distal to the fistula (Figure 1). Subsequent contrast-enhanced computed tomography demonstrated significant pneumobilia and a perforated duodenal ulcer (Figure 2). Removal of the obstructing gallstone was unsuccessful despite using a Raptor grasping device, Roth net retriever, and snare. Patient subsequently underwent exploratory laparotomy with cholecystectomy, pyloric exclusion, Roux-en-Y gastrojejunostomy, and duodenal enterorrhaphy with Graham patch (Figure 3). He tolerated the procedure well and was discharged to a rehabilitation facility. DISCUSSION: Bouveret Syndrome is a rare form of gallstone ileus characterized by gastric outlet obstruction secondary to gallstone impaction within the duodenum or pylorus through a cholecystoduodenal or choledochoduodenal fistula. Prompt imaging is warranted and in patients with gallstone ileus, may reveal pneumobilia, bowel obstruction, and ectopic gallstone, also known as Rigler's triad. Enterolithotomy, gastrostomy with cholecystectomy, and fistula repair are considered the mainstay of management, but prompt gastroenterological evaluation is warranted to evaluate the possibility of mechanical extraction or stone fragmentation.