Bouveretʼs Syndrome

Abstract

Purpose: Case: An 82-year-old female with a history of coronary artery disease presented with 4 days of nausea, bilious vomiting, and epigastric pain radiating to left scapula. On exam she was afebrile, BP 157/64 mmHg with abdominal distention, epigastric tenderness, tympanic on percussion and decreased bowel sounds. The laboratory results include Cr 3.2 mg/dl, BUN 30 mg/dl, alkaline phosphatase 146 IU/L, ALT 19 IU/L, AST 23 IU/L, total bilirubin 1.0 mg/dl, amylase 710 IU/L, lipase 133 Units/L and WBC of 6200 cells/cu.ml. CT scan of abdomen (Figure 1) showed pneumobilia, choledochoduodenal fistula (CBD and 2nd part of duodenum) and a large 3.6 cm gallstone obstructing the distal duodenum. This was consistent with gallstone ileus. The upper GI endoscopy confirmed the impacted gallstone, which could not be extracted endoscopically. The patient underwent jejunal enterolithotomy for gallstone removal and right hemicolectomy with ileotransverse colon anastamosis for ischemic ascending colon found intraoperatively. The postoperative course was complicated by NSTEMI, pulmonary edema requiring mechanical ventilation, bacillus bacteremia and DIC manifesting as hemoperitoneum. Over the course of hospital stay, bilirubin trended upto 35 mg/dl (direct bilirubin -19.8 mg/dl), INR to 2.6, AST 203 IU/L, ALT 65 IU/L on post op day 22 but Alkaline phosphatase was normal. Abdominal USG did not show any biliary dilatation. The patient died 22 days after surgery secondary to cardiac arrest. Discussion: Bouveret's syndrome is a rare variant of gallstone ileus caused by the migration of the large biliary calculus [>2 cm] through cholecystoduodenal or choledochoduodenal fistula resulting in duodenal obstruction. The characteristic radiographic picture is the Rigler's triad of bowel obstruction, pneumobilia and a gallstone in small bowel. Upper GI endoscopy is diagnostic in 69% of cases. If the endoscopic removal fails, the most common surgical therapy is enterolithotomy with or without cholecystectomy and fistula repair. Other options include extracorporeal shock wave lithotripsy, electrohydraulic lithotripsy or mechanical lithotripsy.Figure