Cholecystoduodenal Fistula Research Articles

When cholecystostomy tube and transpapillary stents for recurrent cholecystitis fail due to large gallstones: rescue with laser lithotripsy via cholecystoduodenal fistula.

Surgical candidates with acute cholecystitis and symptomatic cholelithiasis have conventionally been managed with cholecystectomy. Alternative interventions for nonoperative candidates include percutaneous gallbladder drainage or endoscopic decompression through ERCP and cystic duct stents.1,2 Percutaneous drains have inherent limitations and drain-related issues: pain, bleeding, obstruction, leaking, and dislodgement. Furthermore, they may fail to achieve definitive decompression, especially in cases of large-volume cholelithiasis.

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.

S1586 Upper Gastrointestinal Bleeding as a Warning Sign for a Rare Cholecystoduodenal Fistula

INTRODUCTION: Cholecystoenteric fistulas are rare, observed in approximately 1 out of every 10,000 cholecystectomies. Its symptoms are usually non-specific, making clinical diagnosis challenging and leading to intraoperative diagnosis. Upper gastrointestinal bleed (UGIB) is an infrequent manifestation of this entity. We present the case of a 71 year old male who experienced an UGIB and was later diagnosed with a cholecystoduodenal fistula intraoperatively. CASE DESCRIPTION/METHODS: A 71 year old man presented to the ED complaining of melena and weakness. Patient was tachycardic and his hemoglobin was 10 gm/dL from a baseline of 15 gm/dL. A CT scan with oral contrast showed a high-density mural thickening of the duodenum that extended contiguously to involve the gallbladder wall and hepatic flexure of the colon (Figure 1). An upper endoscopy was performed that showed the oozing duodenal bulb ulcer with an adherent clot. Endoscopic treatment was unsuccessful due to the location of the ulcer. Interventional radiology performed embolization of the right gastric, right gastroepiploic, and right gastroduodenal artery. His hemoglobin stabilized and the patient was discharged home. Due to his CT findings, he underwent colonoscopy 2 months later. A mass was found in the proximal transverse colon near the hepatic flexure concerning for malignancy (Figure 2). Biopsies showed inflamed granulation tissue but no dysplasia or malignancy. However, due to suspicion of malignancy, the patient underwent right open hemicolectomy with ileocolic anastomosis. Intraoperatively, he was found to have a cholecystoduodenal fistula and required a partial cholecystectomy and repair of the fistula via omental patch. Postoperatively, the patient did well with normalization of his hemoglobin. DISCUSSION: Cholecystoenteric fistulas, most commonly cholecystoduodenal fistulas, are rare and usually a late complication of cholelithiasis disease. The occurrence of severe UGIB due to cholecystoduodenal fistulas is unnusual, making it difficult to diagnose. UGIB is usually caused by a marginal ulcer in a site of erosion by the enteric fistula. In our case, it is likely patient had cholecystodudoenal fistula secondary to a perforating duodenal ulcer rather than cholelithiasis which is the cause in most cases of cholecystoenteric fistula. It appears that his colonic mass was inflammatory from the perforated ulcer. It is important to recognize cholecystoduodenal fistula as an associated complication of duodenal ulcer.Figure 1.: High density mural thickening of the duodenum, extending contiguously to involve the gallbladder wall and hepatic flexure of the colon.Figure 2.: Transverse colon mass found during colonoscopy.

S1597 The Curious Case of a Missing Gallbladder: An Unusual Presentation of a Large Gallstone and Cholecystoduodenal Fistula

INTRODUCTION: Cholecystodudenal fistula is a rare complication of cholelithiasis. We present a unique endoscopically-treated case of a 5 cm gallstone that caused acute abdominal pain without gastric outlet obstruction in a middle-age female. CASE DESCRIPTION/METHODS: A 56-year-old woman with DM type II, hypertension, and BMI of 48 kg/m2 presented with acute right upper quadrant pain for 3 days. It was associated with nausea but no emesis, aggravating or alleviating factors. She had no prior abdominal surgeries. Vitals were normal. There was tenderness in the right upper quadrant but Murphy’s sign was negative. WBC, ALT, AST, total bilirubin and lipase were within normal limits. An ultrasound showed gallstones in a contracted gallbladder with no signs of cholecystitis. Robotic-assisted laparoscopic cholecystectomy was attempted, however, there was substantial amount of adhesions. Lysis of the adhesions was performed, then the duodenum and the stomach were found adhered to the gallbladder fossa. Thus, cholecystectomy was not deemed safe and the surgery was aborted. MRCP showed a minimal fluid collection in the gallbladder fossa but no evidence of bile duct stones or dilation. The gallbladder could not be identified. HIDA scan did not show it either. A CT scan of the abdomen revealed a cholecystoduodenal fistula along with air in a non-dilated biliary tree. EGD revealed a 5 cm golden-brown and hard stone and an inflamed and scarred fistulous opening in the bulb. The stone was too large to be retrieved through the pylorus. To prevent GI obstruction and to avoid a high-risk laparotomy, a large snare with a hard wire was used to break it down by forcefully pulling it against the plastic tip of the snare. The fragments were brought to the stomach for further fragmentation. The fragments were retrieved using stone baskets. Following the procedure, the symptoms improved. DISCUSSION: What was initially thought to be a classic case of symptomatic cholelithiasis was found to be a clinically, surgically, and endoscopically challenging cholecystoduodenal fistula. The fistula was not seen during an attempted cholecystectomy, nor was it seen on MRCP. Only CT then endoscopy revealed it. Large gallstones causing fistulas are very rare in the young. Laser, extracorporeal shockwave, and intracorporeal electrohydraulic lithotripsies have been used to treat large gallstones. Due to our limited resources, we performed mechanical fragmentation using the readily available stiff snares and stone baskets; a rarely reported approach.Figure 1.: Coronal oral and intravenous enhanced CT image of the abdomen demonstrates a large calculus (yellow arrow) with a few foci of air, as well as air within the biliary system (green arrow) suggesting choleduodenal fistula. A small amount of ascites surrounds the liver. There is also subcutaneous air within the right abdominal wall and adjacent to the gluteal muscles due to recent laparoscopy.Figure 2.: Endoscopic view of a large golden-brown, smooth and hard gallstone in the duodenal bulb. Erosion is seen on the wall of the duodenum.Figure 3.: Fragmentation of the large gallstone using a large-opening hard wire snare.

S2772 Bouveret Syndrome: Using Electrohydraulic Lithotripsy to Clear the Way

INTRODUCTION: Bouveret syndrome is a rare form of gallstone ileus that occurs by passage of a gallstone through an acquired cholecystoduodenal or cholecystogastric fistula into the enteric lumen leading to gastric outlet obstruction. It is seen in less than 0.5% of patients with cholelithiasis and represents 1-3% of all gallstone ileus cases. Although several cases of Bouveret Syndrome exist within the literature, we describe a rare case using electrohydraulic lithotripsy (EHL) as a successful treatment option. CASE DESCRIPTION/METHODS: A 67-year-old man with past medical history significant for metastatic melanoma and history of locally advanced tonsillar carcinoma presented to the hospital with acute onset nausea, vomiting, and abdominal pain for 2-day duration. On physical exam, he was afebrile and hemodynamically stable. His abdomen was mildly distended and tender without guarding. Lab assessment was unremarkable. An abdominal computed tomography (CT) revealed a cholecystoduodenal fistula and an obstructing calcified stone in the duodenum with pneumobilia (Figure 1). After a discussion with surgery, the patient was taken for an esophagogastroduodenoscopy (EGD) revealing a large, approximately 3 cm stone completely occluding the duodenal sweep (Figure 2). EHL under water immersion was used to break up the impacted stone. Small pieces were continuously removed from the duodenal lumen with a tripod grasper and placed in the stomach where they were further fragmented. Following gallstone clearance, a large ulcer and cholecystoduodenal fistulous tract was present in the duodenal sweep (Figure 3). The patient did well after the procedure and discharged home without complications. DISCUSSION: Being that Bouveret syndrome is rare and symptoms are nonspecific, a high clinical suspicion needs to exist to make an accurate diagnosis. Imaging findings suggestive of Bouveret syndrome include a dilated stomach, pneumobilia, and a radio-opaque shadow suggesting a gallstone. These findings make up Rigler's triad. Treatment options include surgery and endoscopic interventions. Multiple endoscopic modalities are utilized for the treatment of this syndrome including removal baskets, mechanical lithotripsy, electrohydraulic lithotripsy, and laser lithotripsy. EHL is commonly used, but only successful in 10 % of cases. Although reports of endoscopic success are poor in the literature it should be attempted to decrease the morbidity and mortality associated with surgery that can be as high as 25%.Figure 1Figure 2Figure 3

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.

Gallbladder-duodenal fistula detected by ultrasound - a case report.

Gallbladder-duodenal (cholecystoduodenal) fistula is an uncommon bilioenteric fistula between the gallbladder and the duodenum. It usually occurs following a chronic case of cholecystitis upon which the gallbladder adheres to the adjacent duodenum, and a stone penetrates through the wall. The case presented herein is that of a gallbladder-duodenal fistula detected primarily with the use of ultrasound imaging, and subsequently confirmed by computed tomography. The patient is a 54-year-old woman who was admitted with upper abdominal pain. The fistula was caused by chronic cholecystitis, however no gallstones were present in the duodenum. Surgical management was undertaken for the patient, and the recovery was uneventful.

Haemobilia due to a ruptured right hepatic pseudoaneurysm secondary to Mirizzi syndrome with simultaneous cholecystoduodenal fistula

Haemobilia due to a ruptured right hepatic pseudoaneurysm secondary to Mirizzi syndrome with simultaneous cholecystoduodenal fistula

Tríada de Rigler


 Paciente de 68 años, sin antecedentes quirúrgicos.
 Ingresó a Emergencia con cuadro clínico de oclusión intestinal. Se solicitó radiografía simple de abdomen (solamente se obtuvo en decúbito), observándose la presencia de la tríada radiológica de Rigler, patognomónica del ileo biliar.
 Se señalan los 3 elementos: asas de delgado dilatadas (flecha negra), aerobilia (flecha blanca) y el cálculo calcificado ectópico en la fosa ilíaca derecha (flecha amarilla).
 El íleo biliar es la oclusión intestinal como consecuencia de la migración de un cálculo biliar a través de una fístula bilio-digestiva y su impactación, frecuentemente a nivel de la válvula ileo-cecal. Habitualmente se trata de una fístula colecisto-duodenal, aunque también puede tratarse de una fístula colecisto-colónica.
 El cuadro clínico clásicamente descrito es el de una oclusión intermitente, siendo más frecuente en pacientes añosos, con larga historia de litiasis biliar sintomática.

Rigler’s triad in a case of gallstone ileus

Background: gallstone ileus is a rare complication of cholelithiasis. It is defined as a mechanical obstruction of the small bowel due to impaction of large gallstones into the gastrointestinal tract, generally though a cholecystoduodenal fistula. Rigler’s triad (pneumobilia, ectopic gallstone and mechanical obstruction) occurs in 30% of the patients. Surgery is indicated and includes enterotomy with gallstone extraction. Objective: we report a case of gallstone ileus with radiographic evidence of Rigler’s triad

Post-cholecystectomy Gallstone Ileus.

Gallstone ileus is an unusual complication of cholelithiasis. Classically, a stone is impacted at the terminal ileum originating from a cholecystoduodenal fistula. Exceptions to this pathophysiology have been noted at each step. In this systematic review, we document a comprehensive review of postcholecystectomy gallstone ileus inclusive of 49 separate cases and report 8 different mechanisms leading to this unusual complication. The most common mechanism is a lost stone during cholecystectomy that then erodes through the intestinal wall leading to bowel obstruction. Our review showed an older, female predominance (64.0%) at an average age of 68.0 years, patients typically had a burden of comorbidities. Delay in diagnosis was common (64% of cases) with the correct diagnosis made in 37.5% of patients during admission. Pneumobilia was commonly reported (29.0%). There was a wide range in the amount of time between cholecystectomy and gallstone ileus, from 10 days to 50 years (mean 12.4 years). Postcholecystectomy gallstone ileus is an unusual complication of cholelithiasis, which mandates surgery. Retrieval of stones should be undertaken if they are spilled during cholecystectomy. Owing to the increasing age of the American patient population, it is likely that a higher number of patients with this condition will be encountered.

Cholecystoduodenal Fistula Causing Gallstone Ileus

Gallstone ileus is a rare disease, and it accounts for 1–4% of all cases of mechanical intestinal obstruction. Incidence is more in elderly with a female predominance and may result in a high mortality rate. The diagnosis of gallstone ileus is difficult, and early diagnosis could reduce the mortality. Surgery is the mainstay of treatment. Here, we are reporting a case of 65-year-old lady presented as intestinal obstruction and later diagnosed to have cholecystoduodenal fistula causing gallstone ileus.

Bouveret’s syndrome and cholecystogastric fistula: a case-report and review of the literature

An exceptionally rare cause of gastric outlet obstruction, Bouveret's syndrome results from proximal impaction of an ectopic gallstone, enabled by fistulization that aberrantly connects the biliary and luminal gastrointestinal tract, typically a cholecystoduodenal fistula. It occurs with a 2:1 female predominance, most often in the eighth decade of life. Endoscopic treatment is the preferred first-line strategy in management, followed by surgical intervention if unsuccessful. Endoscopy failed to retrieve the stone due to its size, despite attempted lithotripsy, which prompted laparoscopic retrieval. Bouveret's syndrome compels a high index of suspicion in proximal gastrointestinal obstruction even when presenting in a male a decade younger than the median age of diagnosis (74years), with no preceding biliary symptoms particularly as early intervention can considerably reduce morbidity and mortality.

SMALL INTESTINAL OBSTRUCTION AS A RARE COMPLICATION OF GALLSTONE DISEASE

Small intestinal obstruction is a very rare complication of gallstone disease. It occurs when large stones are found in the gallbladder for a long time, which penetrate into the lumen of the duodenum through the cholecysto-duodenal fistula. Obstruction is more often observed in the terminal part of the ileum. The clinic is atypical and has a two-phase character. At the beginning of the disease, the clinic resembles acute cholecystitis, and then the clinical picture of acute intestinal obstruction develops. With the viability of the small intestine, the enterolithotomy is the optimal operation.

Laparoscopic subtotal cholecystectomy a salvageable procedure in patients with comorbidities

Aim: Our aim of study to show the feasibility and outcomes of laparoscopicsubtotal cholecystectomy in presence of difficult calot’s triangle anatomy, even inpresence of cormobidities.Materials & Methods: This study involved a retrospective analysis of patientsmanaged by laparoscopic subtotal cholecystectomy from January 2014 toDecember 2019. Here we analyzed the demography, indications, associated comorbidity,complications, management and their outcomes.Results: During this study period 53 cases underwent LSTC (laparoscopicsubtotal cholecystectomy), Median age of patients was 52 years (range 31-76years). 33 (62.26%) frozen calot’s triangle was the main peroperative findings inthese cases. The infundibulum of gall bladder was mainly managed byendosuturing of the stump (n=21) rest of cases managed by an Endo GIA (n=7),serial metallic clipping (n=2) and in 4 cases stump was left unsutured with onesubhepatic drain placement, 1 case omentum sutured over the cystic duct stumpanother 1 case of cholecystoduodenal fistula was repair with vicryl 3-0. Therewere (n=18) type I, (n=24) type II, (n=11) type III laparoscopic subtotalcholecystectomy done in our study. Two (3.77%) patients had postoperativemorbidity. 1 (1.88%) case had a postoperative bile leak which was successfullymanaged by ERC and stenting. None of the case had a wound infection or intraabdominal collection; there was no mortality and no bile duct injury. The medianpostoperative stay was 4 days (range 2-16 days). The mean follow up durationwas 60 months and the outcome was excellent in all the patients.Abbreviation: ERC (Endoscopic Retrograde Cholangiography), LSC(Laparoscopic Subtotal Cholecystectomy), GB (Gall Bladder),Conclusions: In scenario of difficult calot’s triangle, laparoscopic subtotalcholecystectomy is an effective and safe option, which shows excellentpostoperative recovery and ensures a satisfactory functional outcome for thepatient gall stone disease even in presence of comorbidities.Clinical Significance:KEYWORDSLaparoscopic cholecystectomy, Laparoscopic Subtotal cholecystectomy, difficult cholecystectomy.

Bouveret's syndrome and biliary ileus. An extremely rare cause of gastric obstruction

Blackground: Bouveret’s syndrome and biliary ileus, an extremely rare cause of gastric obstruction (about 300 cases published about Bouveret’s syndrome), is due to the impaction of a duodenal calculus secondary to a cholecystoduodenal or cholecystogastric fistula. It is associated with women, with more than 70 years old and large gallstones. The surgical treatment depends of the patient, the side of the calculus and its location. Surgical treatment is enterolithotomy with or without cholecystectomy. The fistula can close spontaneously so its repair may be unnecessary. The aim is to present two cases of biliary ileus and we do a bibliographic review to know its management. Material & Methods: The first patient was an 81 years old male who consulted in the emergency room for oral intolerance and vomiting. A CT study was performed, finding a cholecystoduodenal fistula and lithiasis that causes intestinal obstruction in the duodenum (figure 1). The other patient, was an 91 years old female who consulted in the emergency room for vomiting. In CT we could see a cholecystoduodenal fistula and a lithiasis in ileon that caused intestinal obstruction. Results: First patient underwent surgery with enterolithotomy. Six days after surgery, the patient was discharged home without symptoms. In the second case, the patient needed surgery with enterolithtomy, cholecystectomy and closure of the duodenum. In Conclusion: in these patients, intestinal obstruction must be treated first with an enterolithotomy and a biliary procedure, including cholecystectomy and biliary-enteric fistula closure, in low-risk patients.

Ultrasonografski pregled abdomena kao dovoljan dijagnostički modalitet u postavljanju dijagnoze bilijarnog ileusa - prikaz slučaja

Introduction: Biliary ileus is a rare emergency condition that mainly affects the elderly population, with a predominance of females and a mortality rate of 12-27%. It is a mechanical intestinal obstruction caused by the impaction of the biliary calculus within the gastrointestinal tract. It occurs due to the formation of bilio-enteric fistula, as a rare complication of cholelithiasis. Case report: A 73-year-old male patient with epigastric pain, nausea and vomiting was referred for ultrasound exam. The analysis of the clinical-biochemical status of the patient as well as the ultrasound examination of the abdomen itself raised the suspicion of small intestine obstruction, due to the enclaved biliary calculus. After an urgent exploratory laparotomy, the diagnosis was confirmed, and enterotomy was successfully performed with calculus extraction. Cholecysto-duodenal fistula has been confirmed as a major cause of biliary ileus. The post-operative course was uneventful. Conclusion: This case report highlights the enormous importance of ultrasound diagnostics in diagnosing biliary ileus using the criteria of The Rigler Triad, which includes pneumobilia, intestinal obstruction and ectopic calculus. Initially unrecognised cause of obstruction and a late diagnosis correlated with bad prognosis. Ultrasonographic examination of these patients can be a sufficient diagnostic modality in making an accurate diagnosis and further surgical treatment of these patients

Complications from an Atypical Presentation of a Cholecystoduodenal Fistula

Complications from an Atypical Presentation of a Cholecystoduodenal Fistula

A Case of Gallstone Ileus with Cholecystoduodenal Fistula Treated by Single–port Laparoscopic Surgery

A Case of Gallstone Ileus with Cholecystoduodenal Fistula Treated by Single–port Laparoscopic Surgery

Síndrome de Bouveret, una causa extraña de obstrucción intestinal alta: reporte de caso

El síndrome de Bouveret (SB) es una patología poco frecuente, la cual se caracteriza por la presencia de obstrucción gástrica o duodenal secundaria a un cálculo enclavado en la luz duodenal, el cual migra a través de una fístula colecistoduodenal. Su incidencia es de alrededor 1% al 3% de todos los casos de íleo biliar. Los principales síntomas consisten en vómito, dolor abdominal, hematemesis, pérdida de peso y anorexia. En el 91% de los casos se requiere manejo quirúrgico. En este artículo se presenta un caso de un paciente de 50 años, con cuadro clínico de 2 meses de evolución de dolor abdominal en epigastrio y mesogastrio, distensión abdominal y múltiples episodios de emesis. Al examen físico con clínica de obstrucción intestinal se realizó tomografía abdominal, donde se evidenció obstrucción intestinal por imagen intraluminal en primera porción duodenal asociada con tríada de Rigler, con diagnóstico de síndrome de Bouveret.