S1531 Hard to Stomach: Gallstone Ileus as a Result of Mirizzi-Induced Bouveret Syndrome

Abstract

INTRODUCTION: Appropriate escalation of care in acute cholecystitis can be both lifesaving and cost-effective. We report a patient with Bouveret syndrome as an unintended consequence of Mirizzi type Vb with subsequent development of gallstone ileus. It is known that Bouveret syndrome is a particularly rare form of gallstone ileus that results as a result of a cholecysto-enteric fistula entering into either the duodenum or stomach. And while gallstone ileus represents 0.3%-0.5% of all mechanical small bowel obstructions, Bouveret syndrome represents approximately 1%-3% of those gallstone ileus cases. Mirizzi syndrome and its stages are sequela of a single, large, or many small gallstones impacted in Hartmans’s pouch or in the gallbladder infundibulum and cystic duct. When chronic or unaddressed, this pathology progresses insidiously to present as in the case of our patient. CASE DESCRIPTION/METHODS: A 73 year old female presented to the ED with a 3-week history of right-upper quadrant pain. Subsequent workup revealed a chronic cholecystitis with cholelithiasis. She was stabilized and instructed to follow up with a surgeon for elective cholecystectomy at a later day. A year later she presented again with severe abdominal pain with emesis. Imaging showed a large stone causing gastric outlet obstruction and the presence of a cholecystoduodenal fistula. A nasogastric tube was placed and the patient had an emergent EGD performed to remove the stone however it was unable to dislodged despite two separate attempts. Consequently, she went for an ex-lap where a gastro-jejunostomy was performed due the severely friable state of the gastric tissue surrounding the impacted stone. Patient recovered well until her fifth day post-op when she developed significant abdominal distention and pain; imaging now revealed a terminal ileum gallstone ileus. She successfully underwent another laparotomy and was discharged home. DISCUSSION: This patient developed advanced and exceptionally rare intra-abdominal pathology that was difficult to treat as a result of delayed surgical intervention. The chronicity of her cholecystitis led to an advanced stage of Mirizzi syndrome that dovetailed with a gastric-outlet obstruction. Patients cannot be relied upon to follow up diligently in the outpatient setting and therefore need prompt evaluation on initial presentation. Had this patient received specialty consultation at her initial encounter, the potentially disastrous and financially burdensome chain-of-events, may have been avoided.Figure 1.: CT scan showed a large stone causing gastric outlet obstruction and cholecysto-duodenal fistula.Figure 2.: Impacted gallstone causing gastric outlet obstruction.