Bouveretʼs Syndrome: An Uncommon Complication of Cholelithiasis

Abstract

Purpose: An 84-year-old Caucasian female presented with nausea, vomiting, and abdominal pain. Four years previously, she had an episode of cholecystitis and cholelithiasis that was treated with antibiotics. She declined surgical therapy but was asymptomatic in the ensuing years. During the current illness, her abdomen was soft with mild palpable tenderness in the mid-epigastrium. Bowel sounds were normal and no masses were noted. Laboratory testing including CBC, electrolytes, liver enzymes, and amylase were normal. CT scan showed air in the biliary tree with distention of the duodenum and stomach. Jejunum and ileum were not dilated. Abdominal series showed air fluid levels in the stomach and duodenum, and air in the biliary tree, but no free air was noted. During upper GI endoscopy, the esophagus and stomach were normal; the duodenal bulb contained two ulcers and an ulcerated fistula that led to the gall bladder. Large stones were found in the gallbladder. Retained solid food was in the duodenal bulb. The second portion of the duodenum below the ampulla was obstructed by a large gallstone. The stone could not be removed via endoscopy. The patient underwent an exploratory laparotomy resulting in an enterolithotomy with fistula repair and cholecystectomy. An obstructing gallstone measuring approximately 5 cm was found at the ligament of Treitz. The patient made an uneventful recovery and was discharged home after 9 days. Bouveret's syndrome is an uncommon complication of gall bladder disease resulting from passage of a gallstone through a cholecystoenteric fistula that causes a proximal bowel obstruction. It is a form of gallstone ileus resulting from an impacted gallstone in the duodenum or pylorus. Patients typically present with epigastric pain, nausea, and vomiting. The average age of a patient with the syndrome is 74.1 years of age (SD±11.1) and is more frequent in women (1.86 female/male ratio). Less than 0.5% of patients with cholelithiasis will develop gallstone ileus; however, in patients over 65 years of age it accounts for 25% of nonstrangulated bowel obstructions. Gallstone ileus only accounts for 1-4% of cases of intestinal obstruction. Of gallstone ileus cases, only 1-3% are Bouveret's Syndrome. The majority of gallstones in the bowel impact at the ileoceaccal junction. Rigler's triad of gallstone ileus includes pneumobilia, small bowel obstruction, and a gallstone. CT scan will detect all three signs of Rigler's triad in 78% of cases. Diagnosis of Bouveret's Syndrome is made in 69% of cases by upper GI endoscopy. If removal is not possible endoscopically, enterolithotomy with or without cholecystectomy and fistula repair is the most common surgical therapy.