Duodenal Obstruction by a Gallstone: A Rare Case of Bouveretʼs Syndrome

Abstract

Background: Bouveret's syndrome is duodenum obstruction due to a gallstone impaction and is a rare complication cholecystitis. It should be included in differential of any patient presenting with a clinical picture of gastric outlet or proximal small bowel obstruction. A combination of CT imaging and upper endoscopy (EGD) is critical in making a preoperative diagnosis. Case Report: A 78-year-old male with history of dementia presented to the emergency room with an episode of projectile vomiting and severe abdominal pain. On physical exam he appeared ill with fever and tachycardia. His abdominal exam was significant for tenderness in epigastrium, without peritoneal signs. A CT scan showed a focal filling defect in proximal small bowel of unclear etiology. Contrast did not flow beyond that point. There was no air in the billiary tree. He was treated with NPO status and antibiotics and an EGD was preformed. At endoscopy a dark-colored “sphere-like” object was noted impacted in the lumen of the descending duodenum and it was immediateley recognized by the endoscopist to be a gallstone (Figure 1). Exploratory laprotomy confirmed the diagnosis and a 3 cm gallstone was removed from duodenum via anterior pylorotomy. Due to significant inflammation in right upper quadrant, and no residual stone in gallbladder, cholesytectomy and the closure of fistula was not performed. Patient did well after the surgery and was discharged back to nursing home. Discussion: Gallstone ileus is an unusual complication of cholelithiasis, occurring in less than 0.5 percent of patients. Bouveret's syndrome is the term used to describe a duodenal or gastric outlet obstruction secondary to an impacted gallstone in the duodenum or pylorus. The presenting symptoms of this rare entity are epigastric pain, nausea, and vomiting. The diagnosis can be suggested based upon a plain radiograph, although CT may offer better visualization of the impacted stone. Plain abdominal films may demonstrate air in billiary tree (Rigler's sign) only in half of the cases. Surprisingly, the diagnosis is made preoperatively in only about one-half of cases, and early endoscopy can be very helpful. An early endoscopy should be considered in any elderly patient presenting with gastric outlet obstruction signs and symptoms.Figure: [954]