Two Obstructions, One Stone: Gastric Outlet Obstruction and Gallstone Ileus Secondary to One Gallstone?

Abstract

Bouveret syndrome is a rare cause of gastric outlet obstruction, secondary to impaction of a gallstone either within the pyloric channel, or in the duodenum. This occurs typically via a cholecystoduodenal fistula, often a sequela of cholecystitis and pericholecystic inflammation. The patient is a 73 year old Caucasian female, otherwise healthy, who presented with epigastric pain and abdominal bloating for five days. Her symptoms progressed to intractable nausea with bilious emesis. CT imaging revealed calculus cholecystitis with pneumobilia, cholecystoduodenal fistula with a 25mm gallstone impacted in the pyloric channel, and a dilated, fluid-filled stomach consistent with gastric outlet obstruction. Nasogastric tube placement resulted in ˜600mL of bilious output with prompt resolution of symptoms. She was subsequently transferred to our tertiary care center. Initial EGD showed reflux esophagitis, a large amount of retained food in the stomach, and an impacted gallstone protruding from the pyloric channel. Several modalities were attempted to dislodge the stone including a lithotripsy basket, a balloon catheter over guidewire, and grasping forceps. All were unsuccessful. Given the inability to visualize the duodenal lumen distal to the stone, additional attempts were deferred until repeat EGD with fluoroscopy the next day. Repeat EGD was notable for absence of the previously seen stone in the pyloric channel. The stone was visualized under fluoroscopy in the mid-small bowel. The cholecystoduodenal fistula was noted in the duodenal bulb along the anterior wall and was traversed with the endoscope. Two large stones (15mm and 40mm) were impacted at the proximal end of the fistula without complete obstruction of the gallbladder resulting in adequate biliary drainage. Repeat imaging showed migration of the gallstone into the proximal ileum with proximal small bowel dilatation and air-fluid levels consistent with low grade small bowel obstruction. She underwent laparoscopic-assisted enterolithotomy with resolution of the small bowel obstruction. Repeat EGD with electrohydraulic lithotripsy was planned. Our case highlights the natural course of Bouveret syndrome, but is unique in that it presented as a gastric outlet obstruction, followed by spontaneous migration of the gallstone to cause low-grade small bowel obstruction. This also stresses the importance of timely endoscopic intervention, as delay in therapy may necessitate surgical intervention.Figure 1Figure 2