Bouveretʼs Syndrome: A Challenging Cause of Gastric Outlet Obstruction

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Bouveret's syndrome is a clinically distinct form of gallstone ileus caused by the formation of a fistula between the gallbladder and duodenum, where typically a large gallstone is impacted in the pylorus or proximal duodenum. This rare condition could be associated with high morbidity and mortality rates, hence increased awareness is waranted. We report a case of Bouveret's syndrome in a patient with gastric outlet obstruction due to a 7 cm gallstone chronically impacted in proximal duodenum. 78-year-old male with history of atrial fibrillation and COPD presented with epigastric pain and bilious vomiting of 1 week duration. Physical exam revealed abdominal distension. Laboratory tests revealed elevated WBCs, liver enzymes and lipase. CT scan of abdomen showed a 7 x 4.4 cm gallstone in proximal duodenum, a cholecystoduodenal fistula and pneumobilia (Figure 1). EGD revealed a complete obstruction secondary to a stone impacted beyond the duodenal bulb (Figure 2). Endoscopic removal was attempted initially, aiming to fragment the stone via mechanical and electrohydraulic (EHL) lithotripsy. The large size was a limitation to the mechanical approach. EHL was partially effective in fragmenting the stone despite using the highest available energy level and multiple catheters. Other tools were attempted thereafter in order to pull the stone in the stomach for further fragmentation, including fluoroscopy assisted wire-guided biliary balloon, assisted TTS dilation balloon extraction, snare assisted and loop assisted removal. The stone was adherent to the wall of the duodenum. The patient underwent successful surgical removal of the stone through duodenotomy (Figure 3) followed by cholecystectomy and cholecystoduodenal fistula repair. Patient did well postoperatively.Figure 1Figure 2Figure 3Bouveret's syndrome is an uncommon cause of gastric outlet obstruction and an important diagnosis worth considering especially in patients with history of biliary colics, large gallstones or chronic cholecystitis. Abdominal imaging and endoscopy are the mainstay of diagnosis. Treatment options include endoscopic and surgical management. Endoscopic removal should always be attempted first, despite the reported limited success rate of 10%. The addition of mechanical and/or electrohydraulic lithotripsy has been used with some success. Surgery is required in over 90% of cases, with mortality rates ranging from 19% to 24%. Surgical options include enterotomy and removal of stone with or without cholecystectomy and repair of fistula, or gastric bypass surgery. In this case we present a unique case of chronic Bouveret's syndrome where the size (7 cm) and adherence of the impacted stone to the duodenal wall was a major limitation hindering the success of the endoscopic approach. Increased clinical awareness is of utmost importance for the timely management of this rare syndrome.