GALLBLADDER ADENOCARCINOMA PRESENTING AS BOUVERETʼS SYNDROME

Abstract

Introduction: Cholelithiasis is a common problem in the United States. In rare instances a cholecystoduodenal fistula may form. A large gallstone may pass through this fistula and move into the duodenum. These patients may present with gastric outlet obstruction (Bouveret's Syndrome). Case Report: A 72-year old woman with a history of coronary artery disease and hypertension presents with acute onset of bilious vomiting and abdominal pain. She denied any prior gastrointestinal symptoms or weight loss. A CBC revealed a white blood cell count of 12,100, hemoglobin of 13.7, hematocrit of 42.9, and a platelet count of 434,000. Total bilirubin was 0.4 and alkaline phosphatase of 202. An ultrasound of the gallbladder showed cholelithiasis without common bile duct dilatation or evidence of cholecystitis. An abdominal x-ray was nonspecific. An esophagogastroduodenoscopy revealed a large obstructing stone composed of both black and brown pigment in the second part of the duodenum. A lithotriptor cracked 25–30% of the 8×4 cm stone however; the entire stone could not be obliterated. The patient was taken to surgery later in the day. She had an open cholecystectomy and repair of a cholecystoduodenal fistula. The pathology showed gallbladder adenocarcinoma, invasive into the submucosa. Discussion: Bouveret's syndrome is a rare occurrence in patients with cholelithiasis. It occurs most commonly in women (65%) with a median age of 68 years. A specific etiology has not been discovered. The diagnosis is made by endoscopy (60%), upper GI series (45%) or x-ray (23%). Mortality has improved from 33% in 1968 to 12% in recent years. The pathogenesis of Bouveret's syndrome is formation of a cholecystoduodenal fistula secondary to inflammation of the gallbladder wall. The inflammation may be due to a number of causes including cholecystitis or possibly adenocarcinoma as in this case. Conclusion: Bouveret's syndrome may be suspected in a patient with known gallstone disease who presents with recent emesis. However, most cases of gallstone obstruction occur in the ileus. Radiologic or endoscopic workup may be necessary to confirm the diagnosis. Therapy includes multiple types of intervention, ranging from endoscopic laser or lithotripor ablation to surgery.