Acting Fast: A Case of Spontaneous Calculus Migration in a Patient with Bouveretʼs Syndrome

Abstract

Bouveret's syndrome describes impaction of the duodenum resulting from the passage of a gallstone through a bilioenteric fistula, often presenting diagnostic and therapeutic challenges. Although individualized therapy is recommended in these unique cases, it has generally been accepted that endoscopic retrieval is inferior to surgery due to the large size of most of these calculi. When endoscopy is attempted, it often causes fragmentation of the calculus with migration of fragments to the distal small bowel. Stone migration has previously been described also through surgical fragmentation, and one recent case of migration after contrast administration. We present the case of a 60-year-old morbidly obese male with a history of lap band surgery who presented to the emergency room with sudden onset of nausea and vomiting.The patient was found to be in hemodynamically stable condition and initial labs were notable for an elevated direct bilirubin of 1.3, normal liver function, and alkaline phosphatase of 203. MRCP revealed a cholecystoduodenal fistula and an obstructing 3 cm gallstone within the proximal duodenum resulting in gastric dilatation. Endoscopy was performed and revealed a large cratered duodenal ulcer with a fistulous opening distal to the pyloric channel (Image 1). The stone was not visualized. A repeat CT-scan showed gallstone ileus with progression of the large stone from the duodenum to the distal jejunum/proximal ileum loops, with moderate small bowel obstruction (Image 2). He was taken to surgery for a laparoscopic enterotomy and gallstone extraction, whereby a 5x3cm stone was successfully removed from the distal jejunum (Image 3). The patient had a complicated post-op course, requiring intubation and pressor support in the intensive care unit. To our knowledge, this is the first case of spontaneous calculus migration resulting in ileocecal impaction and necessity for surgery in a high-risk patient. Surgery overall remains the most common approach in these patients who are usually elderly and have multiple comorbidities, and may therefore at least partially explain the persistently high mortality associated with Bouveret's syndrome. We propose that the risk of attempting endoscopy due to possible fragmentation should not prevent this from being considered the initial recommended approach, as the calculi may migrate spontaneously regardless and surgery is often life threatening in this population of patients.1367_A.tif Figure 1: Cholecystoduodenal Fistula1367_B.tif Figure 2: Stone MIgration1367_C.tif Figure 3: Stone extraction - Gross Specimen