Endoscopic Management of Bouveretʼs Syndrome in a Patient with Cholecystoduodenal Fistula

Abstract

Background: Bouveret's syndrome occurs when a gallstone passes through a cholecystoduodenal fistula (CDF) and obstructs the duodenum resulting in gastric outlet obstruction. It is a rare variant of gallstone ileus with an overall incidence of 1-3%. Bouveret's syndrome poses an unique diagnostic and therapeutic challenge for clinicians due its rarity and unpredictable symptomatology. Case Presentation: An 81 year old female presented with an acute onset of nausea, vomiting and right upper quadrant abdominal pain. Physical examination was unremarkable except for tenderness of the right upper quadrant. No leukocytosis was present. Transaminases were AST 43, ALT 42, alkaline phosphatase 266 and total bilirubin 0.7. Computed tomography of abdomen revealed a CDF with a 4x3cm gallstone in the proximal portion of the duodenum causing obstruction. An upper endoscopy was subsequently performed, revealing a 4cm impacted stone at the junction of the first and second portion of the duodenum, along with a CDF containing a 2cm gallstone. A large stone fragment was successfully retrieved using a lithotripsy basket after performing a 20mm balloon dilation of the pylorus. A second upper endoscopy was performed with the remaining portions of the stone being crushed using an Olympus lithotripter. A magnetic resonance cholangiopancreatography revealed choledocholithiasis with multiple stones and sludge in the distal common bile duct. An endoscopic retrograde cholangiopancreatography was performed, at which time a 15mm biliary sphincterotomy was made and the biliary tree was swept with a 15mm balloon starting at the bifurcation, resulting in complete removal of stones and sludge.Figure 1Figure 2Discussion: The majority of patients with a CDF are elderly with a female preponderance. In about 60% of these cases the fistula is cholecystoduodenal. Typical symptoms of Bouveret's syndrome include nausea, vomiting and epigastric abdominal pain. The pathophysiology of this syndrome results from the increase in intraluminal pressure caused by obstruction, leading to ischemia and necrosis, allowing the gallstone to perforate the gallbladder and intestinal wall. Gallstones larger than 2.5cm usually become impacted in the gastric outlet. Endoscopic intervention with a lithotripsy balloon is a safe and effective first line of treatment for Bouveret's syndrome, considering that the majority of patients are elderly with multiple comorbidities and a high perioperative surgical risk.Figure 3