Bouveret Syndrome Missed by a Whisker: A Case Report

Abstract

Background: Gallstones ileus is a rare cause of intestinal obstruction secondary to gall stone causing bilioenteric fistula. The stone commonly lodges in the distal ileum, colon or duodenum and the least common site of obstruction is the proximal duodenum/pylorus causing gastric outlet obstruction (Bouveret's syndrome). We present a case of endoscopic removal of a large gallstone impacted in the first part of duodenum. Case summary: A 61-year-old male patient, presented with symptomatic choledocholithiasis and cholelithiasis. He underwent ERC, sphincterotomy, bile duct clearence and stenting 3 months back. He was planned for cholecystectomy. Laparoscopy could not separate gall bladder from its fossa and was converted to open surgery. But open cholecystectomy was abandoned in view of dense adhesions and adherent gall bladder. He had nausea and epigastic pain for 2 weeks without jaundice or vomitting or constipation. Endoscopy was performed which showed a large cholecystoduodenal fistula on the posterior wall of first part of duodenum. Endoscopic stone retrival was attempted but failed inspite of use of snare forceps/roth net forceps. He was admitted for evaluation and reattempt under anaesthesia. He had routine blood investigations which were normal. MRCP abdomen was done which showed contracted gall bladder with calculi and wall thickening, adhered to duodenum with perilesional lymphnode. Repeat endoscopy was attempted under general anaesthesia and the stone was retrieved peicemeal using roth net forceps and basket. Conclusion: Endoscopic stone retrieval can be attempted in cases of large cholecystoduodenal fistula. The authors have none to declare.