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Oblique ultrasound right upper quadrant of abdomen demonstrates fistulous communication (arrow) between the gall-bladder (GB) and duodenum (D), residual calculus seen within the gallbladder with associated posterior acoustic shadowing.
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p>Bouveret's syndrome is a well known clinical entity; its incidence however, is uncommon. An unusual complication of cholelithiasis, Bouveret's syndrome should be considered in an elderly patient presenting with acute gastric outlet obstruction.
We describe a case of an elderly female patient presenting with acute gastric outlet obstruction secon...
Context in source publication
Context 1
... imaging revealed pneumobilia with complex inflammatory change between the gallbladder and duodenum, with appearances highly suggestive of a cholecystoduodenal fistula (Fig. 1); the distal small bowel was seen to be collapsed whilst the stomach was distended and fluid filled. Further evaluation with abdominal contrast enhanced computed tomography (CT) confirmed the fistulous connection between gallbladder and duodenum with a large (4.8cm maximum diameter) gallstone impacted in the duodenal cap with resultant gastric outlet obstruction -Bouveret's syndrome (Fig. ...
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Background
Duodenal obstruction due to a gallstone, also known as Bouveret’s syndrome, is one type of gallstone ileus. This is a rare complication of cholelithiasis. Among gallstone ileus cases, duodenal obstruction is alsorare. Apart from rareness, diagnosis is challenging due to unspecific clinical manifestation. Treatment options have benefits a...
Bouveret's syndrome is a rare complication of cholelithiasis, characterized by gastric outlet obstruction caused by a migrated gallstone. Diagnosis of Bouveret's syndrome necessitates urgent treatment as it carries a high mortality rate. The treatment of Bouveret's syndrome has traditionally been surgical. However, there have been increasing report...
A cholecystoenteric fistula is an anomalous communicating tract between the gallbladder and any segment of the gastrointestinal tract. It is a rare complication of gallstone disease and typically affects elderly patients with multiple medical comorbidities. These fistulae can present in a variety of ways, and the diagnosis is often made only after...
We describe a case of a 63-year-old male with complicated Bouveret's syndrome, both in its presentation and in its management. Bouveret's syndrome is a rare cause of gastric outlet obstruction resulting from mechanical obstruction from gallstones at the pyloroduodenal segment. As Bouveret's syndrome can be a diagnostic and therapeutic challenge for...
Laparoscopic cholecystectomy is the standard treatment for cholelithiasis. A very rare condition named situs inversus should not be considered as a contraindication for laparoscopic cholecystectomy. Here, we reported a case of successful laparoscopic cholecystectomy in a patient with situs inversus totalis. We also described the technical advantage...
Citations
... It may result from large gallstones eroding through the gallbladder wall to the adjacent intestines or stomach. 1,2 We present a unique case of a middle-aged woman with a 5-cm gallstone found in the duodenum that caused acute abdominal pain without gastric outlet obstruction (GOO) and was treated endoscopically. ...
... 1,2 Larger gallstones that could lead to gallstone ileus typically present at older ages with mean age 70 to 75 years old, affecting women more than men. 1,2,4 In addition to gallstone ileus, impaction of a large stone in the pylorus or duodenum may result in GOO; the hallmark of a rare entity called Bouveret's syndrome. Various minimally invasive treatment modalities have been utilized to treat large gallstones. ...
... Notwithstanding, it is reasonable to attempt the minimally invasive upper endoscopic therapeutic interventions prior to surgery, unless there is gallstone ileus. 1,2,5,[11][12][13][14][15] In summary, this was an unusual case of cholecystoduodenal fistula with a large gallstone in the bulb without causing GOO at a relatively young age, which was treated successfully by using readily available stiff wire snares to achieve safe and controlled mechanical lithotripsy. ...
Large gallstones could erode through gallbladder wall to nearby structures, causing fistulas, gastric outlet obstruction and gallstone ileus. They typically occur in elderly patients with comorbidities carrying therapeutic challenges. We present a case of a middle-aged woman who was thought to have symptomatic cholelithiasis. Extensive adhesions precluded safe cholecystectomy. While hepatobiliary iminodiacetic acid scan and magnetic resonance imaging with cholangiopancreatography (MRI-MRCP) failed to visualize the gallbladder, computed tomography (CT) was consistent with cholecystoduodenal fistula. A very large gallstone was seen endoscopically in the duodenum, which was broken down into pieces using a large stiff snare.
... Gallstone ileus occurs in 0.3-0.5% of patients presenting with cholelithiasis, and Bouveret's syndrome represents only 1-3% of these cases [1,2]. However, Bouveret's syndrome has considerable morbidity and mortality rates ranging from 12 to 30% due to significant associated patient comorbidities [3,4]. Due to the disease rarity, there have been no standardized recommendations for management with a wide variety of management techniques including endoscopic and surgical options. ...
Bouveret’s syndrome is a rare complication that occurs most commonly in elderly patients with multiple comorbidities. It is secondary to an impacted gallstone causing gastric outlet obstruction from a cholecystoduodenal fistula, and there is no defined standardized management in current literature. A 92-year-old woman presents to our tertiary community hospital with abdominal discomfort concerning for bowel obstruction. Computed tomography revealed pneumobilia with a cholecystoduodenal fistula and a large gallstone in the proximal duodenum causing gastric outlet obstruction. The impacted gallstone failed endoscopic extraction with electrohydraulic lithotripsy, and patient subsequently developed distal gallstone ileus requiring exploratory laparotomy and enterolithotomy. This case report examines the need for early coordinated endoscopic and surgical management of a patient with Bouveret’s syndrome complicated by gallstone ileus as it is associated with high morbidity and mortality rates.
... U 1 % -3 % slučajeva žučni kamenac može zapriječiti dvanaesnik, obično u distalnom dijelu. Utjecaj na piloričnu regiju i gornji dio dva-naesnika te posljedično opstrukciju pilorusa (Bouveretov sindrom) najrjeđi je [3][4][5][6] . Diferencijalna dijagnoza kod starijih osoba dijeli se na tri skupine: upalna, maligna i urođena etiologija bolesti. ...
Sažetak. Cilj: Prikazati slučaj pacijentice s akutnim abdominalnim bolom i Bouveretovim sindromom kao rijetkom komplikacijom kolecistolitijaze. Prikaz slučaja: Osamdesetogodišnja pacijentica primljena je u hitnu medicinsku službu zbog bolova u epigastriju i gornjem abdomenu uz povraćanje tamnog sadržaja koji traju unazad tri dana. Posljednja stolica pacijentice bila je uredna, uredne diureze i pacijentica je bila afebrilna. U laboratorijskim nalazima vrijednosti upalnih parametara bile su neznatno povišene. Učinjen je ultrazvuk abdomena koji je pokazao skvrčeni žučnjak s kamencima. Nativna snimka abdomena nije pokazala znakove pneumoperitoneuma i ileusa. Pacijentici je ordinirana ulkusna terapija s naglaskom da se javi na kontrolni pregled ako se stanje pogorša. Dva dana nakon prijama pacijentici se stanje pogoršalo te dolazi u gastroenterološku ambulantu, gdje joj je učinjena ezofagogastroduodenoskopija (EGDS) koja je pokazala tamnozeleni sadržaj u lumenu jednjaka i želuca te zaglavljen velik kamenac u pilorusu, zbog čega je pacijentica hospitalizirana. Drugog dana hospitalizacije pacijentici se ponovio EGDS s neuspješnim ishodom. Trećeg dana hospitalizacije pacijentici je neuspješno učinjena hitna eksplorativna laparoskopija i operativni zahvat se konvertirao u desnu subkostalnu laparotomiju, te je gastrotomijom ekstrahiran žučni kamenac. Pacijentici je dalje učinjena gastroenteroanastomoza i entero-enteralna anastomoza po metodi Braun, uveden je dren subhepatalno i rana je zašivena po slojevima. Postoperativni tijek kompliciran je infekcijom operacijske rane. Pacijentica je otpuštena dvadesetdrugog postoperativnog dana te nije imala bilijarnih smetnji u sljedećih šest mjeseci praćenja. Zaključak: Uzrok akutnog abdominalnog bola nerijetko može biti i komplikacija kolecistolitijaze. U rijetkim slučajevima kolecistolitijaza se može komplicirati žučnim kamencem prisutnim izvan žučnjaka koji migirira kroz biliogastričnu ili bilioduodenalnu fistulu s opstrukcijom pilorusa (Bouveretov sindrom), što predstavlja životno ugrožavajuće stanje uz smrtnost od 12 % do 30 %. Abstract. Aim: To present a case of a patient with acute abdominal pain and Bouveret's syndrome as a rare complication of cholecystolithiasis. Case report: An eighty-year-old patient was admitted to the emergency department for upper abdominal pain and vomiting of dark content lasting three consecutive days. The patient had regular bowel movements, with normal stool and diuresis and normal body temperature. Laboratory findings showed slightly elevated values of inflammatory parameters. Abdominal ultrasound showed a crumpled gallbladder with gallstones. Radiographic tomography showed no signs of pneumoperitoneum and ileus.The patient was prescribed gastric antisecretory therapy with warning to come back if symptoms got worse. After two days the patient returned with more severe symptoms. An upper gastrointestinal (GI) endoscopy showed dark green content in the esophagus and stomach with a large gallstone obstructing the pylorus, which was the
... Se define como la presencia de una fístula bilioentérica, la cual permite el paso de cálculos biliares hacia el duodeno, que en su migración proximal hacia el píloro genera una obstrucción del drenaje gastroduodenal (2,3). La fístula es producto de un proceso inflamatorio crónico con aumento de la presión intraluminal, acompañado de isquemia de pared, con un sistema de adherencia y ulterior perforación, lo que conlleva a una comunicación entre el sistema biliar y el intestino, con el paso de cálculos biliares (4,5). ...
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.
... Bouveret's syndrome describes gastric outlet obstruction secondary to an impacted gallstone that reached the small bowel through a bilioenteric fistula. The formation of the fistula is a consequence of the chronic inflammation and adherence between the biliary system and the bowels, increasing the intraluminal pressure and causing wall ischemia and wall perforation with gallstone passage into the bowel [2,3]. ...
... Despite the rarity of Bouveret's syndrome, it can cause notable morbidity and mortality rates. The critical association between the rarity and severity of this syndrome should be an incentive for spreading more awareness of its occurrence [2,3]. ...
... That further pushes towards an earlier diagnosis, for the affected population is of an advanced age, with frequent associated comorbidities, which increase the morbidity and mortality risks. Due to improved diagnostic techniques and more restrictive surgical approaches, the mortality rate of Bouveret's syndrome decreased from 30% to around 12% [2][3][4]. ...
It was in 1896 that Bouveret’s syndrome acquired its name after the French physician Leon Bouveret, who published two case reports in Revue de Medecin. Bouveret’s syndrome describes gastric outlet obstruction secondary to an impacted gallstone. The gallstone reaches the small bowel through a bilioenteric fistula as a consequence of chronic inflammation and adherence between the biliary system and the bowels which increase the intraluminal pressure and leads to secondary wall ischemia and wall perforation with gallstone passage into the bowel. Bouveret’s syndrome’s prevalence is highest among elderly women. Despite the rarity of Bouveret’s syndrome, it can cause notable morbidity and mortality rates. We underwent a review of literature about Bouveret syndrome to increase awareness of its occurrence and potentially life-threatening complications.
... Less frequent ones include Mirizzi syndrome, cholecystenteric fistula, and gallstone ileus [4]. Several isolated cases have been described of cholecystocolonic fistula and gallstone ileus [5]. ...
Patient: Female, 16 Final Diagnosis: Malrotation and cholecystoduodenal fistula Symptoms: Abdominal pain • anorexia • fever • nausea • vomiting Medication: - Clinical Procedure: - Specialty: Gastroenterology and Hepatology.
Anatomical anomaly/variation.
Cholecystoduodenal fistula (CDF) is the most common cholecystenteric fistula. It is a late complication of gallbladder disease with calculus and is mainly encountered in the elderly and females.
We report the case of a teenage patient with cholecystoduodenal fistula and malrotation. Direct plain abdominal x-ray demonstrated air in the biliary system. Computed tomography revealed CDF-associated with an anomaly of intestinal malrotation. She had gallstones (with a few stones in the gallbladder) and cholecystitis. CDF is caused by malrotation, and cholecystitis has not been reported before. In this regard our patient is the first and youngest reported case.
We suggest that CDF is probably a consequence of malrotation. The patient's clinical features and operative management are presented and discussed with current literature.
... Thus, CT is the imaging modality of choice for diagnosis as well as for determining the level of obstruction, number and size of the calculi, and extraluminal complications. [5,[7][8][9] Magnetic resonance cholangiopancreatography (MRCP) may be useful in cases where gallstones are isoattenuating as it can easily distinguish between fluid and calculi. MRCP can also depict the cholecystoduodenal fistula if sufficient fluid is present as described by Pickhardt et al. in their case. ...
Introducción. El síndrome de Bouveret es una variante del íleo biliar, de rara presentación dentro de las causas de obstrucción intestinal, generada por la impactación de un lito biliar a nivel del duodeno, secundario a la formación de una fístula bilioentérica. Es más común en mujeres en la octava década de la vida, con múltiples comorbilidades. y presenta síntomas inespecíficos, documentándose la triada de Rigler hasta en el 80 % de las tomografías de abdomen. La cirugía sigue siendo el tratamiento de elección.
Caso clínico. Presentamos el caso de una paciente de 76 años, con múltiples antecedentes y cuadros previos de cólico biliar, que consultó por dolor abdominal y signos de hemorragia de vías digestivas altas y se documentó un síndrome de Bouveret. Fue tratada en la misma hospitalización mediante extracción quirúrgica del cálculo con posterior resolución de su sintomatología.
Conclusión. A pesar de que el síndrome de Bouveret es una entidad de infrecuente presentación, los cirujanos generales deben estar familiarizados con esta patología, en el contexto del paciente que consulta con un cuadro de obstrucción intestinal, conociendo el valor de la tomografía de abdomen y la endoscopia de vías digestivas altas, teniendo en cuenta la edad y las condiciones del paciente para definir el manejo quirúrgico más adecuado.
Bouveret syndrome is a rare cause of gastric outlet obstruction. It is characterised by the presence of an obstructing gallstone in the pylorus or proximal duodenum, which has travelled to its obstructing position via an acquired fistula. Our case involves a 73-year-old man presenting to the acute surgical take with a 2-day history of right-sided abdominal pain and vomiting. His medical history included perforated cholecystitis treated with antibiotics and percutaneous gall bladder drainage, 1 year earlier. Examination and blood tests were suggestive of gastric outlet obstruction. CT abdomen and pelvis demonstrated a large gallstone obstructing the duodenum, confirming a diagnosis of Bouveret syndrome. The patient improved following gastrolithotomy, and was discharged 2 weeks postoperatively. Fistula formation is a complication of chronic cholecystitis and therefore Bouveret syndrome should be considered in patients with a background of gallstone disease presenting with gastric outlet obstruction.
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.
