EP-90 Bouveret Syndrome: A challenging case of impacted gallstone within the fourth part of the duodenum

Abstract

Abstract Aims Bouveret syndrome is a rare condition characterised by gastric outlet obstruction secondary to a gallstone fistulating into the proximal duodenum or pylorus. We present a case of a 68-year-old with recurrent small bowel obstruction secondary to a large gallstone impacted in the fourth part of the duodenum and cholecysto-duodenal fistula. We describe our atypical approach to surgical retrieval. Methods The patient presented acutely with abdominal pain and vomiting, on a background of recent admission for gallstone ileus managed conservatively. Initially, due to high anaesthetic risk (P POSSUM score = 14% mortality, 60% morbidity), the patient was managed conservatively with nasogastric drainage and total parenteral nutrition. On day 6 of admission, emergency laparotomy was performed after identifying radiological signs of impending perforation and clinical deterioration. Endoscopic management was not available locally. The stone could not be milked proximally for retrieval via pyloroplasty. Subsequently, high-pressure water flushes delivered via the gastrostomy expelled the stone distally. The stone was then retrieved via a jejunotomy at the DJ flexure. Results The patient required a 2-day high dependency unit admission and she was discharged 3 weeks post-operatively at her functional baseline. She was clinically well and asymptomatic when reviewed at the four-month post-operative surgical follow-up appointment. Conclusions This is the first report to our knowledge to describe successful surgical management of a gallstone impacted in the fourth part of the duodenum. Enterolithotomy can be considered safe option in patients with large, impacted stone and multiple co-morbidities.