S2791 Bouveret Syndrome: An Unusual Cause of Gastric Outlet Obstruction (GOO)

Abstract

INTRODUCTION: Bouveret syndrome is an extremely rare clinical condition caused by gallstone ileus due to cholecystoduodenal or cholecystogastric fistula in the setting of cholecystitis. The impacted gallstone in the duodenum causes gastric outlet obstruction, manifesting as epigastric pain, nausea, and vomiting. Owing to its scarcity of reported cases, diagnosing and treating this syndrome is challenging. Our case report emphasizes the early recognition of a clinical syndrome, which should suggest Bouveret syndrome rather than other causes of gastric outlet obstruction, such as malignancy. CASE DESCRIPTION/METHODS: A 68-year-old female with a past medical history of cholelithiasis and hypothyroidism presented with a 2-day history of epigastric pain. The pain was located in the epigastric region, associated with nausea and vomiting. Labs were non-significant except for mild leukocytosis. CT revealed numerous gallstones with gallbladder wall thickening, along with markedly dilated stomach with pyloric wall thickening showing partial gastric outlet obstruction (GOO) (Figure 1). RUQ ultrasonogram showed WES sign and DISIDA scan showed cystic duct obstruction, CT guided biopsy was done at GB wall and pylorus but was negative for malignancy. EGD showed high-grade pyloric stricture causing a GOO for which NG tube was placed. TPN was initiated and EGD was reattempted on hospital day 9, which showed a small fistulous opening in the gastric antrum along with a gallstone partially filling the duodenal bulb. The gallstone was noted to “ball-valve” in the area with insufflation and suction via the scope. The findings were consistent with Bouveret syndrome, which was corroborated on MRCP (Figure 2). The patient underwent open partial cholecystectomy, repair of cholecystoduodenal fistula, gastrojejunostomy, and enterolithotomy on hospital day 14. Post-operatively, the patient had delayed recovery of gastric function and required prolonged nasogastric tube placement. The recovery was also complicated by Bacteroides Fragilis bacteremia. The patient was eventually discharged on hospital day 29. DISCUSSION: Calculous cholecystitis with gastric outlet obstruction is a clinical situation, which Bouveret syndrome should be considered strongly. Since the majority of patients are old and have other comorbid conditions, the mortality rate is higher than those with other causes of mechanical small bowel obstruction. Maintaining a high level of suspicion can avoid delay in the diagnosis and can lead to timely surgical interventions.Figure 1.: Gallstones filling the gallbladder with wall thickening and pericholecystic fluid. Markedly distended stomach with pyloric wall thickening concerning for GOO.Figure 2.: Cholecystitis with findings suspicious for a cholecystoduodenal fistula and 2.9cm gallstone in the region of the first portion of duodenum, suggestive of Bouverete syndrome.