Bouveret’s syndrome complicated by a distal gallstone Ileus

Synchronous Gallstone Ileus and Bouveret’s Syndrome: A Report of Two Rare Concurrent Complications of Gallstone Disease

Cholecystoenteric fistulas occur as a result of a chronic inflammatory insult involving the gallbladder and the erosion of both its wall and a bowel segment. When the fistula develops, it creates a pathway for gallstones to migrate and cause an intestinal obstruction, known as gallstone ileus. When it obstructs the gastric outlet, a proximal variant of gallstone ileus occurs, known as Bouveret's syndrome. A 65-year-old man presented to the emergency department with a three-day history of epigastric and right upper quadrant pain and persistent vomiting, preceded by unintentional weight loss of 15 kg over three months. Endoscopic and complementary imaging studies identified a concurrent gastric outlet obstruction caused by a lodged gallstone in the duodenal bulb and gallstone ileus. The patient underwent an urgent exploratory laparotomy and was submitted to an enterolithotomy and gastrolithotomy. Due to a sudden deterioration on the fourth postoperative day, he underwent an emergent re-laparotomy that found fecal peritonitis and complete dehiscence of both closures. The patient was then managed with damage control surgery. An atypical gastric resection and enterectomy of the distal ileum were performed and the patient was admitted to the intensive care unit in temporary abdominal closure (laparostomy). The patient failed to improve and died on the same day. Ultimately, the patient's multiple comorbidities, including morbid obesity, malnutrition, and diabetes, contributed to poor tissue healing and the fatal outcome. Gallstone ileus and Bouveret's syndrome are two rare complications of cholecystoduodenal fistulas that have not yet been reported to occur simultaneously. Both intestinal and gastric obstruction makes the surgical approach the first-line treatment.

Bouveret Syndrome: A Rare Case and Review of the Literature

Bouveret syndrome is a subtype of gallstone ileus, wherein a calculus becomes entrapped in the duodenum via a cholecystocolic fistula, leading to gastric outlet obstruction. Due to the non-specific symptoms the patients present with, a diagnosis is reliant on computed tomography (CT), magnetic resonance imaging (MRI) or direct endoscopic visualisation. We report a case of Bouveret syndrome and review current literature, outlining the aetiopathogenesis and management strategies of this condition.

Endoscopic lithotripsy for Bouveret syndrome complicated by small bowel obstruction secondary to gallstone fragments

Bouveret syndrome is a rare complication of cholecystitis, in which impaction of a gallstone creates a cholecystoduodenal fistula leading to gastric outlet obstruction. We report a case of a 90-year-old female who presented with nausea and vomiting on a background of previous necrotic cholecystitis managed conservatively. Computed tomography of the abdomen demonstrated a large gallstone impacted in the third part of the duodenum leading to gastric outlet obstruction. Given her frailty, the patient underwent endoscopy to relieve the obstruction; however, complete retrieval of the gallstone fragments after lithotripsy was not possible. She subsequently developed distal gallstone ileus due to migration of the gallstone fragments and underwent laparotomy, enterotomy and retrieval of the fragments. This case highlights the dilemma of managing elderly patients with Bouveret syndrome with open or endoscopic surgery and the importance of retrieving all gallstone fragments after lithotripsy to avoid iatrogenic complications, such as gallstone ileus.

A Rare Case of Cholecystoduodenal Fistula with Rapid Distal Gallstone Migration

Patient: Female, 51-year-old

Final Diagnosis: Cholecystoduodenal fistula

Symptoms: Nausea • non-bilious emesis • right upper quadrant abdominal pain

Medication: —

Clinical Procedure: —

Specialty: Surgery

Bouveret Syndrome: A Systematic Review of Endoscopic Therapy and a Novel Predictive Tool to Aid in Management

BACKGROUND AND GOALS

Bouveret syndrome is characterized by gastroduodenal obstruction caused by an impacted gallstone. Current literature recommends endoscopic therapy as the first line of intervention despite significantly lower success rates compared with surgery. The lack of treatment efficacy studies and the paucity of clinical guidelines contribute to current practices being arbitrary. The aim of this systematic review was to identify factors that predict outcomes of endoscopic therapy. Subsequently, a predictive tool was devised to predict the success of endoscopic therapy and recommendations were proposed to improve current management strategies of impacted gallstones in the upper gastrointestinal tract.

METHODS

A systematic search of PubMed, Medline, Cochrane, and Scopus was performed for articles that contained the terms "Bouveret syndrome," "Bouveret's syndrome," "gallstone" AND "gastric obstruction" and "gallstone" AND "duodenal obstruction" that were published between January 1, 1950 to April 15, 2018. Articles were reviewed by 3 reviewers and raw data collated. χ and Kolmogorov-Smirnov tests were used to test associations between predictors and endoscopic outcomes. A logistic regression model was then used to create a predictive tool which was cross validated.

RESULTS

Failure of endoscopic therapy is associated with increasing gallstone length (P<0.0001) and impaction in the distal duodenum (P<0.05). Using multiple endoscopic modalities is associated with better success rates (P<0.05). The novel predictive tool predicted success of endoscopic therapy with an area under the receiver operating characteristic score of 0.86 (95% confidence interval: 0.79-0.94).

CONCLUSION

In Bouveret syndrome, a selective approach to endoscopic therapy can expedite definitive treatment and improve current management strategies.

The curious case of biliary emesis and bowel obstruction from Bouveret syndrome

Bouveret syndrome is a rare complication of biliary lithiasis. This sequela is caused by the passage of the gallstone via a bilioenteric fistula, resulting in an impacted gallstone in the duodenum or stomach. The common presentation of non-specific symptoms contributes to the diagnostic uncertainty and delay, which is strongly associated with adverse outcomes. We report an uncomplicated stone extraction via open gastrotomy in an elderly man afflicted with bowel obstruction and biliary vomit secondary to Bouveret syndrome.

Bouveret Syndrome: When a Stone Cannot Pass the Pylorus

Bouveret syndrome, a rare cause of intestinal obstruction, occurs by passage of a gallstone through a cholecystoduodenal fistula into the intestinal lumen. Presenting symptoms are nausea, vomiting, and abdominal pain. In some cases, chronic symptoms result in weight loss. Typically, the syndrome is diagnosed via x-ray, ultrasound, or computed tomography. Treatment options are endoscopic or surgical. Endoscopic approaches include mechanical lithotripsy, electrohydraulic lithotripsy, stone extraction, laser lithotripsy, extracorporeal shockwave lithotripsy, and/or duodenal stenting. When stone fragments migrate distally, surgical removal becomes necessary. We describe a distinct endoscopic treatment via stone breakage, followed by pushing the fragments of the stone into the jejunum, resolving the intestinal obstruction.

Endoscopic Retrograde Cholangiopancreatography and Endoscopic Ultrasound-Guided Gallbladder Drainage

"Gallbladder disease is one of the most common gastrointestinal diseases encountered in clinical practice. Surgical removal and percutaneous drainage are both widely available and effective in the management of acute cholecystitis. Several endoscopic approaches exist as an alternative to these interventions. These include transpapillary approaches via endoscopic retrograde cholangiopancreatography (ERCP), transmural drainage and access approaches via endoscopic ultrasound (EUS), and endoscopic surgical approaches using natural orifice transluminal endoscopic surgery (NOTES) techniques. This article reviews the epidemiology and pathophysiology of gallbladder diseases and discusses the various percutaneous, surgical, and endoscopic approaches to managing gallbladder disease."

Rare cause of gastric outlet obstruction

Bouveret’s syndrome is a rare cause of gastric outlet obstruction. The stones enter the small bowel via cholecysto-enteric fistula. The most common presenting symptoms are abdominal pain, nausea and vomiting. The gold standard diagnostic test isesophagogastroduodenoscopy (EGD). Rigler’s triad on abdominal x-ray is classic. CT scan findings are pneumobilia, cholecystoduodenal fistula and a gallstone in the duodenum. We present a case of a 75-year-old female who presents with 3 week history of nausea, vomiting, and diffuse abdominal pain. Initial presentation, imaging and EGD was concerning for malignancy. She was later diagnosed to have Bouveret’s syndrome and underwent laparoscopic small bowel enterotomy with removal of gallstones

Novel treatment options for Bouveret's syndrome: a comprehensive review of 61 cases of successful endoscopic treatment

In Bouveret's syndrome, a biliary stone obstructs the duodenum. Surgical treatment is plagued by high morbidity and mortality. Therefore, endoscopic treatment has become a first-line approach. Areas covered: A literature search of Medline and Google Scholar databases was performed using the terms endoscopic treatment, non-operative treatment, Bouveret's syndrome, and gallstone ileus. Sixty-one cases of successful endoscopic treatment were found over the period 1978-2016 and are summarized herein. Therapeutic modalities used in 52 patients with complete success included mechanical lithotripsy (40% of cases), electrohydraulic lithotripsy (21% of cases), extraction of the intact stone and laser lithotripsy (15% of cases each), extracorporeal shockwave lithotripsy and duodenal stenting (4% of cases each). In the remaining 9 patients, stone fragments migrated distally and required surgical removal. Cholecystectomy was performed in five (8.2%) of 61 patients and gallbladder cancer was detected in three (4.9%) patients. Expert commentary: Meticulous preparation, including that of instruments, personnel, patient anesthesia, and X-ray availability, is key to success in this unusual situation. Partial success (stone fragmentation and mobilization to another location) may render surgery easier as these patients present with dense adherences in the right upper quadrant. Cholecystectomy is reserved for highly selected patients (e.g. relapsing ileus, gallbladder cancer).

Bouveret's syndrome complicated by classic gallstone ileus: progression of disease or iatrogenic?

CASE PRESENTATION

Bouveret's syndrome is a rare variant of gallstone ileus resulting in gastroduodenal obstruction from an impacted gallstone. We report two cases of Bouveret's syndrome that were complicated by classic (distal) gallstone ileus, which has previously been reported only twice. The first patient presented with vomiting, epigastric pain, and what was initially believed to be a duodenal diverticulum on computed tomography scan and endoscopy. He initially improved, but later developed symptoms of a small bowel obstruction. Repeat imaging revealed a classic distal gallstone ileus. The second patient presented with nausea, abdominal pain, and imaging consistent with Bouveret's syndrome. Multiple non-operative endoscopic techniques and extracorporeal shock wave lithotripsy were employed to fragment and retrieve the obstructing stone, and she subsequently developed a distal gallstone ileus from a stone fragment. Both patients were managed operatively with enterotomy and stone removal.

DISCUSSION

These cases highlight a rare complication of Bouveret's syndrome, classic (distal) gallstone ileus, and juxtapose the natural history of a stone passing versus an iatrogenic etiology. We review the presentation and management of Bouveret's syndrome though no clear consensus exists as to the optimal treatment of these patients. We recommend that therapy should be decided on a case-by-case basis.

Bouveret's syndrome: presentation of two cases with review of the literature and development of a surgical treatment strategy

BACKGROUND

Bouveret's syndrome causes gastric outlet obstruction when a gallstone is impacted in the duodenum or stomach via a bilioenteric fistula. It is a rare condition that causes significant morbidity and mortality and often occurs in the elderly with significant comorbidities. Individual diagnostic and treatment strategies are required for optimal management and outcome. The purpose of this paper is to develop a surgical strategy for optimized individual treatment of Bouveret's syndrome based on the available literature and motivated by our own experience.

CASE PRESENTATION

Two cases of Bouveret's syndrome are presented with individual management and restrictive surgical approaches tailored to the condition of the patients and intraoperative findings.

CONCLUSIONS

Improved diagnostics and restrictive individual surgical approaches have shown to lower the mortality rates of Bouveret's syndrome. For optimized outcome of the individual patient: The medical and perioperative management and time of surgery are tailored to the condition of the patient. CT-scan is most often required to secure the diagnosis. The surgical approach includes enterolithotomy alone or in combination with simultaneous or subsequent cholecystectomy and fistula repair. Lower overall morbidity and mortality are in favor of restrictive surgical approaches. The surgical strategy is adapted to the intraoperative findings and to the risk for secondary complications vs. the age and comorbidities of the patient.

Congenital duodenal diaphragm in an adult masquerading as superior mesenteric artery syndrome

Persistent congenital diaphragm in the second part of the duodenum may rarely present in adults with features of upper gastro-intestinal obstruction. This possibility is often not considered in adults due to delayed onset of symptoms. One such case is reported in a middle aged male who was diagnosed preoperatively with superior mesenteric artery syndrome. However, on exploration, the duodenal diaphragm was found to be the cause of intestinal obstruction that was managed successfully. This rare clinical entity should be kept as a possibility while dealing with cases of duodenal obstruction in adults so as to avoid missed diagnosis and mismanagement.

"Bouveret's syndrome" presenting with acute pancreatitis a very rare and challenging variant of gallstone ileus

INTRODUCTION

Bouveret's syndrome is a rare variant of gallstone ileus and describes gastric outlet obstruction secondary to an impacted stone in the duodenum. Its presentation is vague and clinical diagnosis is often difficult resulting in a delay in diagnosis.

PRESENTATION OF CASE

We report a patient who presented initially with non-specific symptoms and subsequently with features in keeping with acute pancreatitis, but eventually was found to have Bouveret's syndrome.

DISCUSSION

Different treatment strategies are discussed. Although endoscopic treatment combined with many newer modalities like lithotripsy have been tried, surgery remains the definitive management in the vast majority of cases.

CONCLUSION

Bouveret's syndrome is a rare condition, can also present as pancreatitis and often difficult to diagnose initially, but with appropriate treatment has a good outcome.

Successful Multimodality Endoscopic Treatment of Gastric Outlet Obstruction Caused by an Impacted Gallstone (Bouveret's Syndrome)

Bouveret's syndrome is a rare condition of gastric outlet obstruction resulting from the migration of a gallstone through a choledochoduodenal fistula. Due to the large size of these stones and the difficult location in which they become impacted, endoscopic treatment is unsuccessful and most patients require surgery. We report the case of an elderly male who presented with nausea and hematemesis, and was found on CT scan and endoscopy to have an obstructing gallstone in his duodenal bulb. After several endoscopic sessions and the use of multiple instruments including a Holmium: YAG laser and electrohydraulic lithotripter, fragmentation and endoscopic removal of the stone were successful. We believe this to be the first case of Bouveret's syndrome successfully treated by endoscopy alone in the United States. We describe the difficulties encountered which necessitated varied and innovative therapeutic techniques.

[A rare cause of gastric outlet obstruction: Bouveret's syndrome]

Bouveret's syndrome is a rare type of gallstone ileus in which a gallstone enters the intestinal tract via a cholecystoenteric fistula and is lodged in the duodenum or the stomach. Since the first description by León Bouveret in 1896, fewer than 200 cases have been described in the worldwide literature. Mortality is high, at 25%, but may be related to the advanced age of the typical patient and comorbidities, as well as diagnostic delay. Diagnosis may be made with radiological (abdominal X-ray, ultrasound, computed tomography or magnetic resonance imaging) and endoscopic techniques. Endoscopy is preferred as the first therapeutic option but is frequently unsuccessful and surgery is often required. We present the case of a patient admitted to hospital with a history of vomiting after eating and epigastric pain. The management of this rare cause of gastric outlet obstruction is discussed.

Intermittent gastric outlet obstruction due to a gallstone migrated through a cholecysto-gastric fistula: A new variant of “Bouveret’s syndrome”

Bouveret’s syndrome, defined as gastric outlet obstruction due to a large gallstone, is still one of the most dramatic biliary gallstone complications. Although new radiological and endoscopic techniques have made pre-surgical diagnosis possible in most cases and the death rate has dropped dramatically, “one-stage surgery” (biliary surgery carried out at the same time as the removal of the gut obstruction) should be still considered as the gold standard for the treatment of gallstone ileus.In this case, partial gastric outlet obstruction resulted in an atypical and insidious clinical presentation that allowed us to perform the conventional one-stage laparatomic procedure that completely solved the problem, thus avoiding any further complications.

Migrating gallstone: from Bouveret's syndrome to distal small bowel obstruction

Gallstone ileus is an uncommon cause of small bowel obstruction. When the gallstone lodges inside the duodenum and causes gastric outlet obstruction, it is termed Bouveret's syndrome. However, it is rather unusual to seen the evolution of a migrating gallstone (from duodenum to distal small bowel) in a patient during the same hospital admission. We report a case of gallstone ileus from the initial presentation of gastric outlet obstruction to the development of distal small bowel obstruction within the same hospital admission, and its total laparoscopic treatment.

Biliary stone causing afferent loop syndrome and pancreatitis

We report the case of an 84-year-old female who had a partial gastrectomy with Billroth-II anastomosis 24 years ago for a benign peptic ulcer who now presented an acute pancreatitis secondary to an afferent loop syndrome. The syndrome was caused by a gallstone that migrated through a cholecystoenteric fistula. This is the first description in the literature of a biliary stone causing afferent loop syndrome.

Characterization of Bouveret's syndrome: a comprehensive review of 128 cases

AIM

The aim of the study was to characterize the clinical presentation, evaluation, and therapy of Bouveret's syndrome, by comprehensively reviewing all the identified previously reported cases, to facilitate early diagnosis and thereby to improve the prognosis.

METHODS

Relevant articles were identified by MEDLINE computerized searches, by consultation with all available reference books, and by review of the first author's teaching files. A new case in which the diagnosis of Bouveret's syndrome was missed at esophagogastroduodenoscopy (EGD)--despite endoscopic findings of gastric outlet obstruction caused by a hard, nonfleshy, and convex pyloric mass--prompted this review.

RESULTS

Review of 128 reported cases identified syndromic characteristics. Patients on average were 74.1 +/- 11.1 (SD) yr old. The female-to-male sex ratio was 1.86. Prominent symptoms were nausea and vomiting in 87%, abdominal pain in 71%, hematemesis in 15%, recent weight loss in 14%, and anorexia in 13% of patients. Prominent signs were abdominal tenderness in 44%, signs of dehydration in 31%, and abdominal distention in 26% of patients. Endoscopy revealed gastroduodenal obstruction in nearly all cases, but identified the obstructing stone in only 69%. Abdominal ultrasound or computerized tomography was diagnostic in about 60% of cases.

CONCLUSIONS

The following endoscopic findings are suggestive of Bouveret's syndrome: a dilated stomach containing old digested food from gastrointestinal obstruction together with a hard and nonfleshy mass at the obstruction. These endoscopic findings, in the setting of the currently reported characteristic epidemiologic and clinical findings, should strongly suggest this syndrome. Abdominal ultrasound or computerized tomography is recommended to confirm and extend the endoscopic diagnosis.

Consecutive instances of gallstone ileus due to obstruction first at the ileum and then at the duodenum complicating a gallbladder carcinoma: a case report

Ectopic gallstone obstruction, gallstone ileus, due to cholecystoenteric fistula is an infrequent condition. Its occurrence as a complication of a gallbladder (GB) carcinoma is even more rare. We describe an unusual case of a GB carcinoma complicated by a cholecystoduodenal fistula leading to first gallstone obstruction in the ileum and then, later, in the duodenum, in which an accurate preoperative diagnosis was based on pathognomonic computerized tomography (CT) features. A correct diagnosis of this may be crucial and requires prompt surgical intervention; radiologists should be familiar with their classic CT appearance.

Laparoscopic Management of Gallstone Presenting as Obstructive Gangrenous Appendicitis

We present an unusual case of a 55-year-old man with symptoms of recurrent appendicitis. Laparoscopy revealed a 1.5 cm gallstone impacted at the base of the appendix, leading to gangrenous appendicitis. This patient did not have any features of gallstone ileus. On imaging he had an inflammatory mass in the region of the right iliac fossa with a hyperintense shadow in the cecal area which was reported as an appendicolith. There was no demonstrable cholelithiasis or biliary-enteric fistula. There were dense omental adhesions in the pericholecystic area on laparoscopy. The case was successfully managed by laparoscopic appendectomy with retrieval of the gallstone. No surgery was undertaken for the gallbladder. Diagnosis was confirmed by biochemical analysis of the stone, which contained calcium bilirubinate and cholesterol. A gallstone obstructing the appendicular lumen is a very rare etiology of gangrenous perforation of the appendix peritonitis. This case was successfully managed laparoscopically.