Bouveret's Syndrome Research Articles

Unusual Presentation of Bouveret Syndrome Resulting in Both Gastric Outlet Obstruction and Small Bowel Obstruction with Perforation

Our case describes an 83-year-old female who presented with severe abdominal pain, nausea, and bilious emesis of one day’s duration. She had an endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and percutaneous transhepatic biliary drainage (PTCD) one year prior for choledocholithiasis with acute cholangitis in her home country, Scotland. Unfortunately, while visiting family in the United States, her PTCD became dislodged, and she developed progressive worsening abdominal pain. Computerized tomography of her abdomen showed pneumobilia, perigastric inflammation, a contracted gallbladder, small bowl inflammation with a likely transition point at the mid-jejunum, and a probable duodenal mass. The patient underwent an exploratory laparotomy with intraoperative findings of choledochoduodenal fistula with coincident gastric and small bowel obstruction (SBO) secondary to three large, mixed gallstones. One 3 cm gallstone was located at the pylorus and two (2.3 and 3 cm) gallstones were isolated in the mid-jejunum, with one of those causing isolated transmural pressure necrosis with subsequent perforation. Bouveret syndrome is a rare cause of gastric outlet obstruction (GOO) that manifests via an acquired cholecystoenteric fistula. Our patient presented with a concomitant GOO and SBO with perforation of the mid-jejunum. Timely diagnosis of Bouveret syndrome is essential, as most causes require emergent surgical intervention.

Cholecystogastric fistula in Bouveret syndrome: Case report and literature review.

Introduction and importanceCholelithiasis is the benign bile pathology with major prevalence. A rare condition has been described, when a stone migrates through the duodenum causing small bowel obstruction (SBO), it's known as Bouveret syndrome, and it's attributed to almost 5% of SBO. Just 2% of the cases present with the migration of the stone through a fistula between gastric chamber and gallbladder, with limited reports in the literature.Clinical findingsWe present a case of an 87-year-old male with Bouveret syndrome and a cholecystogastric fistula with a stone in the gastric chamber who underwent laparoscopic gastrotomy to resolve the clinical case.ConclusionBouveret syndrome remains to be a rare condition in benign bile pathology. Individualized treatment should be performed and multidisciplinary approach leads to improved outcomes for the patient.

Endoscopic Holmium Laser Lithotripsy (EHLL) as an Alternative Minimally Invasive Therapy to the Surgical Management of Bouveret Syndrome

Endoscopic Holmium Laser Lithotripsy (EHLL) as an Alternative Minimally Invasive Therapy to the Surgical Management of Bouveret Syndrome

Endoscopic extraction of a large impacted gallstone (Bouveret syndrome with cholecystoduodenal and cholecystocolonic fistula) with a snare through the rectum.

Endoscopic extraction of a large impacted gallstone (Bouveret syndrome with cholecystoduodenal and cholecystocolonic fistula) with a snare through the rectum.

Окремі діагностичні та лікувальні аспекти синдрому Бувере

Актуальність. Проведено аналіз діагностики та лікування хворих зі спайковою хворобою. У 7 зі 188 оперованих пацієнтів спостерігався синдром Бувере, що був діагностований до оперативного втручання лише в одному випадку. Метою дослідження було визначення можливості проведення міні-інвазивних лапароскопічних і лапароскопічно асистованих втручань у хворих із гострою кишковою непрохідністю (ГКН) на тлі жовчнокам’яного ілеусу. Матеріали та методи. Було обстежено 188 хворих (чоловіки та жінки віком від 49 до 89 років), госпіталізованих в ургентному порядку з кишковою непрохідністю, які перебували на лікуванні в стаціонарі хірургічного відділення № 1 Київської міської клінічної лікарні швидкої медичної допомоги впродовж 2006–2016 рр. Результати проведеного лікування показали, що в ургентній ситуації, якою, безумовно, є наявність ГКН, що обумовлена виходом конкременту в просвіт кишки, обсяг оперативного втручання має бути мінімальним і спрямованим на ліквідацію кишкової непрохідності — видалення конкременту шляхом ентеротомії. Висновки. Аналіз діагностичних аспектів показав, що хворим із ГКН доцільно включити до протоколу обстеження проведення ультразвукового дослідження з метою виявлення змін у жовчному міхурі, оцінки характеру його вмісту та ознак ГКН.

A rare variant of ileus - Bouveret's syndrome.

A rare variant of ileus - Bouveret's syndrome.

Bouveret Syndrome - A Rare Form of Gastric Outlet Obstruction

Introduction: Bouveret syndrome is a rare form of gastric outlet obstruction. It is typically diagnosed in frail elderly patients with protracted biliary disease. Thus, it has disproportionally high rates of morbidity and mortality.

Endoscopic removal of gallstone in bouveret syndrome: case report in a tertiary public hospital in federal district of Brazil

Endoscopic removal of gallstone in bouveret syndrome: case report in a tertiary public hospital in federal district of Brazil

Особенности диагностики и тактики лечения больных с билиарным илеусом (20-летний опыт клиники)

Material and methods. The results of diagnostics and surgical treatment of 58 patients with gallstone ileusadmitted to RRCEM in 2001-2020 are presented. There were 16 men (27.6%) and 42 women (72.4%). Theaverage age of the patients was 70.4 ± 6.8 years. 53 (91.4%) patients had small bowel obstruction and 5 (8.6%)pyloroduodenal obstruction (the so-called Bouveret syndrome). The diagnostic process in patients withgallstone ileus included traditional research methods, as well as modern methods of radiation and endovisualdiagnostics.Results. The frequency of gallstone ileus among patients operated on for acute small bowel obstruction was3.1%. The complete Riegler triad in plain radiography of the abdominal cavity, specific for gallstone ileus,is extremely rare, and we noted the combination of small intestinal levels of one of its components in only36.2%. The choice of tactics for surgical treatment of patients with gallstone ileus depended on the establisheddiagnosis and the specific clinical and operational finding.Conclusion. A large number of complications and mortality accompanies surgery for gallstone ileus. The reasonfor this is the elderly and senile age of patients with a large number of concomitant pathologies, late appealability, the difficulty of diagnosis and the invasiveness of the intervention itself. The main way to improvetreatment results in this category is to improve diagnostics and minimize surgical trauma.

Spontaneous Biliary-Enteric Fistulas and Associated Complications: An Overview.

Spontaneous biliary-enteric fistula (SBEF) is an abnormal communication between the biliary tree and the gastrointestinal tract which develops as a result of biliary or gastrointestinal disease. Iatrogenic fistulas, due to surgery or instrumental exploration, are not included in this definition. R. Colombo, in 1559, was the first to describe SBEF as an occasional finding during an autopsy. In almost 90% of cases the cause of SBEF is chronic recurrent cholelithiasis. Less common causes are penetrating peptic ulcers and neoplastic infiltration from the biliary or gastrointestinal tract. The most common type of SBEF is cholecystoduodenal fistula and the least common is choledochoduodenal fistula. There are various complications associated with SBEF but often these are not promptly recognized by patients or physicians and diagnosis and treatment may be delayed for years. The most important complication, which can be considered pathognomonic for SBEF, is gallstone ileus which manifests clinically as acute or chronic mechanical intestinal obstruction. Gallstone ileus, a rather rare complication of a rather common pathology, biliary lithiasis, is found in 0.000015% of hospitalized patients but in 0.0003% of surgical patients. It is mainly found in women over the age of 65, with a male to-female ratio of 1:5. There are various forms of occlusion, related to the sites of gallstone impaction, with various clinical characteristics and degrees of severity. These include Bouveret syndrome ( 10% of cases) with impaction in duodenum or pylorus, and the more common Barnard's syndrome (5-75% of cases) in which the site of impaction is in the terminal ileum right before Bauhin's valve. For diagnosis, the radiological signs which make up Riglerâ??s triad or tetrad, are essential, and are best visible on magnetic resonance. The the gold standard is contrast-enhanced computed tomography scan. Regarding the surgical management, one-stage simple enterolithotomy is reserved for the oldest patients and the most severe cases. Nowadays, is performed more and more frequently by laparoscopy. In more favorable cases radical treatment of the occlusion, the biliary lithiasis and the SBEF is recommended, either as a one-stage procedure or in two stages with the second procedure performed after few weeks.

Stones have been known to move: Bouveret's syndrome treated with cholecystolithotomy after previous episode of gallstone ileus.

Stones have been known to move: Bouveret's syndrome treated with cholecystolithotomy after previous episode of gallstone ileus.

S2515 Where Did You Come From, Where Did You Go? A Tall Tale of Bouveret’s Travels

Introduction: Bouveret syndrome (BS) refers to a gastric outlet obstruction (GOO) secondary to an impacted gallstone in the pylorus or proximal duodenum. Our case describes BS with migrated gallstone to the distal jejunum causing a small bowel obstruction (SBO) successfully treated with prompt interventional endoscopic (IE) intervention. Case Description/Methods: 86-year-old male presented with nausea, vomiting, and hiccups for the past 3weeks. CT revealed dilated stomach, possible GOO. Urgent endoscopy revealed dilated stomach, 1 large completely obstructing, non-bleeding cratered duodenal ulcer, and large impacted gallstone at the distal duodenal bulb. IE consultation prompted repeat EGD 3 days later showed 1cm fistula in the duodenal bulb to the gallbladder remnant, no evidence of residual gallstone in the bulb, second and third portion of duodenum were normal. CT showed SBO with a transition point in left hemiabdomen. Subsequent double-balloon enteroscopy identified 4cm gallstone in distal jejunum causing SBO. Electrohydraulic lithotripsy successfully fragmented the stone (Figure 1). Patient advanced diet and fully recovered. Discussion: Bouveret's syndrome, described in 1770, represents 2–3% of all gallstone-related GOO and 1–4% of all SBOs. Morbidity and mortality rates, about 60% and 30% respectively, are reported in cases where a patient is a nonsurgical candidate due to comorbidities. Large stones typically require surgical intervention and have high mortality (12-27%). Our case describes treatment success with IE.Figure 1.: First EGD: A, severe LA Grade D esophagitis, B-H shows large completely obstructing, non-bleeding cratered duodenal ulcer 30mm, and large gallstone impacted at the distal end of duodenal bulb. Second EGD: I-K Duodenal Fistula, L-N Fistulous connection to Gallbladder Double Balloon Enteroscopy: O, Large impacted gallstone in distal jejunum. P-U electrohydraulic lithotrpsy performed on impacted gallstone, U-V Clearance of broken particles with aggressive flushing, W-Y Fluoroscopic images showing radiolucent defect, Z Resolution of defect on fluoroscopy.

Cholecysto-pyloric fistula with submucosal impaction of gall stone causing gastric outlet obstruction masquerading as a gastric mass, Bouveret Syndrome: case report

BackgroundCholecysto-enteric fistula is a rare complication of cholelithiasis and cholecystitis. Another even rarer complication is proximal impaction of gallstone(s) in gastric pylorus leading to gastric outlet obstruction, known as the Bouveret Syndrome. Only a few cases have been reported in the available literature. It can be confused with a malignant thickening at the pylorus, knowledge of this syndrome helps in arriving at the right diagnosis.Case reportA 52-year-old female patient, who was admitted to our hospital for evaluation of recurrent vomiting and abdominal pain. She was investigated with various imaging modalities including upper gastrointestinal (GI) endoscopy, abdominal ultrasonography as well as Contrast Enhanced Computerized Tomography (CECT) scan of the abdomen. On the outside scan, it was given as a malignant thickening at the pylorus. However, current radiologists felt that imaging findings were not of a typical malignant mass, and suspicion of Bouveret syndrome was given. Intraoperative findings confirmed the diagnosis of Bouveret syndrome. The patient has not experienced any postoperative complications till now.ConclusionBouveret syndrome is associated with significant morbidity and mortality. Being familiar with the imaging appearance of this condition, and differentiating it with malignant thickening can help radiologists avoid unnecessary invasive procedures in such patients. Being a benign etiology, it also helps in a better prognosis.

Post hoc validation of a tool that accurately predicts the outcome of endoscopic therapy in Bouveret syndrome.

BackgroundBouveret syndrome is characterized by gallstone impaction in the upper gastrointestinal tract causing gastric outlet obstruction. In Bouveret syndrome, endoscopic gallstone removal can avert the need for surgery. However, in cases in which endoscopic therapy is unlikely to succeed, endoscopic attempts delay definitive treatment and compound patient risks. We previously developed a model that predicts endoscopic outcomes from data derived through a systematic review. This tool uses gallstone length, site of impaction, and the number of planned methods of lithotripsy to predict the likelihood of endoscopic success with an accuracy of 81.0%. This study aimed to evaluate our tool performance in an independent, non-training data set and assess endoscopic and surgical outcomes.MethodsSystematic searches of the PubMed, Scopus, and Cochrane databases were performed for articles published between 16 April 2018 and 1 June 2021. The data reported after our previous study were harvested and inputted into the tool to evaluate their ability to accurately predict outcomes when compared with actual outcomes.ResultsNewly collated data in fields of interest showed no significant statistical differences compared with previous training data sets. Endoscopic therapy was successful in 41.9% of cases. Gallstones of ≤4 cm had a higher chance of successful endoscopic intervention (odds ratio 6.7, 95% confidence interval 1.7–25.8, P < 0.01). Complications of surgery were reported in 29.5%; there was one fatality reported. Post hoc evaluation of our predictive tool demonstrated an AUROC score of 0.80.ConclusionsWe have demonstrated in an independent data set that the tool can be used to accurately predict outcomes of endoscopic therapy. Patients in whom endoscopic therapy is most likely to fail should be offered an early surgical opinion.

Синдром Бувере (клінічний випадок)

Gallstone disease is one of the most common surgical nosologies, which tends to increase steadily. More than 2.5 million cholecystectomy surgeries are performed annually in the world: in European countries – from 45 to 80 thousand, in the United States – more than 700 thousand choledocholithiasis with the development of mechanical jaundice. Diagnosis of these complications in most cases is not difficult, and the provision of surgical care is standardized. Bouvet’s syndrome (syn. Acute biliary ileus, Gallstone ileus) is a very rare complication of gallstone disease and is caused by the development of inflammatory degenerative-dystrophic changes between the gallbladder and the duodenal wall, leading to the formation of fistulas through which -intestinal tract with the development of obstruction. However, it should be noted that only in 7–10% of cases, the formed fistula can cause the migration of stones and the development of intestinal obstruction. By 2008, only about 300 cases of the syndrome had been described in the world literature. Patients with a long history of stone disease, frequent episodes of exacerbation of cholelithiasis, female gender, old age are the main risk factors for Bouvere syndrome. Compared to other types of mechanical obstruction, the frequency of biliary ileus is only 1–4% and can reach 24% in people over 70 years. The complexity of the diagnosis is due to the nonspecificity of the initial manifestations, comorbidity of patients, late treatment. Postoperative mortality in acute calculous cholecystitis ranges from 0.28% to 3.01% (on average in Ukraine 0.94–0.81%), and in Bouvere syndrome can reach 24%. The main direct causes of death are bleeding, perforation, acute pancreatitis, severe dyselectrolyte disorders. The possibility of widespread use of computed tomography and magnetic resonance imaging greatly simplifies the diagnostic search. However, unfortunately, preoperative diagnosis of the syndrome is achieved only in a quarter of patients. Minimally invasive methods, given the growth of scientific publications and personal experience, can be successfully used to correct this pathology as a final method. A literature review of the etiology, pathogenesis, clinical manifestations, prevalence, methods of diagnosis and treatment of Bouvet syndrome is presented. Clinical case (short description). Presented own clinical observation of Bouvere syndrome in a patient hospitalized in the surgical department of the KNP «Regional Clinical Hospital named after O.F. Gerbachevsky» with the phenomena of duodenal immobility and long history of stone-bearing. Consecutive use of endoscopic and instrumental imaging methods allowed accurate diagnosis, and the use of laparoscopic access made it possible to perform minimally invasive correction of pathology in this patient. Conclusions. Gallstone disease is one of the most common surgical pathologies. Bouvere syndrome is a rare complication of the latter. Clinical symptoms are less specific, so the use of additional instrumental examinations allows accurate preoperative diagnosis. Due to the low efficiency of endoscopic methods of correction surgery is the main tool. The increase in scientific publications on the use of laparoscopic and video-assisting techniques makes it possible to argue about the relatively high efficiency of the latter in the correction of this pathology. The research was carried out in accordance with the principles of the Helsinki Declaration. The informed consent of the patient was obtained for conducting the studies. The authors declare no conflicts of interests. Key words: Gallstone disease, acute intestinal obstruction, Bouveret syndrome.

Bouveret syndrome in a cholecystoduodenal fistula.

The treatment of Bouveret syndrome lacks specific guidelines and is strictly interdisciplinary. Especially, if electrohydraulic lithotripsy is not available and endoscopic removal fails, a timely surgical approach is advised.

Síndrome de Bouveret, una causa infrecuente de obstrucción duodenal.

Resumen El síndrome de Bouveret constituye la variedad más infrecuente de íleo biliar y se describe en la literatura médica como una entidad poco común. Las manifestaciones clínicas son muy inespecíficas y el diagnóstico puede ser tanto endoscópico como radiológico para detectar el cuadro de obstrucción intestinal de forma precoz y ser lo más conservadores posibles, siendo de elección la extracción endoscópica y si ésta fracasa la cirugía. A pesar de todo, la mortalidad en estos pacientes suele ser elevada ya que afecta preferentemente a pacientes ancianos con numerosas comorbilidades, de ahí que consideremos imperativo intentar solucionar el problema mediante técnicas menos agresivas. Presentamos el caso de una paciente de reciente diagnóstico en nuestro hospital, cuyo diagnóstico fue de manera urgente mediante un TC abdominopélvico y tratada mediante enterostomía y extracción del cálculo.

Complex endoscopic management of gallbladder cancer patient with Bouveret syndrome.

Complex endoscopic management of gallbladder cancer patient with Bouveret syndrome.

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

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.

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

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.