An Unusual Cause of Gastric Outlet Obstruction

Abstract

An 84-year-old woman presented with 2-days of epigastric pain accompanied by nausea and coffee-ground emesis. Physical examination revealed mild tenderness in the epigastrium and a succussion splash. Computed tomography of the abdomen demonstrated findings consistent with a gastric outlet obstruction and a large irregular fluid and gas-filled collection centered on the first and second portions of the duodenum (Figure A, arrow). On esophagogastroduodenoscopy, a fistula was found in the gastric antrum (Figure B) with evidence of a large gallstone within the fistula tract (Figure C). This case illustrates Bouveret syndrome, a rare complication of cholelithiasis manifested by gastric outlet obstruction secondary to gallstone impaction in the stomach or proximal duodenum as a result of acquired fistulous communication between the gallbladder and proximal gastrointestinal tract. In this case, surgical management was deferred given the patient’s multiple coexistent medical conditions. Electrohydraulic lithotripsy was performed along with stenting of the fistula under fluoroscopic guidance to prevent further stone impaction (Figure D) and a nasojejunal feeding tube was placed for nutritional support. The patient has returned for routine endoscopic exchange of cholecystogastric fistula stents without recurrence of symptoms related to gastric outlet obstruction.