Proximal duodenal obstruction – Bouveret’s syndrome revisited

A 62-year-old man presented to our emergency department with acute epigastric pain and vomiting. He was found to have elevated markers of inflammation with a white cell count of 16.1 × 10⁹/L and C-reactive protein (CRP) of 30 mg/L (normal < 5 mg/L), impaired renal function with a creatinine of 1.8 mg/dL, and evidence of mild cholestasis with a bilirubin of 1.3 mg/dL and γ-glutamyltransferase (GGT) of 78 IU/L.

Esophagogastroduodenoscopy (EGD) showed grade 3 reflux esophagitis, and 3 L of gastric fluid were aspirated. Passage of the endoscope beyond the pylorus was obstructed by a mass covered with creamy pus ([Fig. 1 a, b]). After the area had been thoroughly flushed, an incarcerated gallstone was found, which was occluding the duodenal bulb with the orifice of the fistula moving relative to the gallstone ([Fig. 1 c]). Endoscopic retrieval (by net, balloon, and snare) failed because of the large diameter of the stone. Computed tomography (CT) scanning revealed an air crescent within the gallbladder and a penetrating gallstone of 3 cm located within the duodenum, which was completely obliterating the lumen ([Fig. 2]), but there were no signs of intra-abdominal perforation.

Fig. 1 Endoscopic transpyloric views showing: a the mass that was obstructing the duodenal bulb; b the mass in close-up view; c the incarcerated gallstone and the orifice of the fistula (arrows), which are visible after thorough flushing of the area.

Fig. 2 Computed tomography (CT) scan showing the gallstone that had penetrated into the duodenum (arrow) and an air crescent in the gallbladder (arrowhead).

During surgery, the penetration of the gallstone through a cholecystoduodenal fistula was confirmed ([Fig. 3]). The large stone could only be removed after fragmentation ([Fig. 4]). Local excision of the fistula tract was performed and the operation was completed by a cholecystectomy. The patient was discharged from hospital a few days later. On follow-up 3 months later, he had no specific complaints.

Fig. 3 Photograph taken during surgery showing the cholecystoduodenal fistula with the cystic (arrowhead) and duodenal (arrow) sections visible. The brownish gallstone is also still in situ.

Fig. 4 Photograph of the fragmented gallstone after removal.

Proximal ileus caused by penetration of a large gallbladder stone is a rare clinical entity that was first described in 1896 by Bouveret [1], but has only rarely been reported since [2]. If technically feasible, endoscopic retrieval and spontaneous regression of the fistula tract have been reported [3] and this approach may be appropriate, especially in older patients or those with comorbidities, if close interdisciplinary follow-up is provided. However, surgical removal of the stone is often the more appropriate solution.

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• References

• 1 Bouveret L. Sténose de pylore adhèrent à la vesicule calceuse. Rev Med (Paris) 1896; 16: 1-16
• 2 Cappell MS, Davis M. Characterization of Bouveret’s syndrome: a comprehensive review of 128 cases. Am J Gastroenterol 2006; 101: 2139-2146
• 3 Rogart JN, Perkal M, Nagar A. Successful multimodality endoscopic treatment of gastric outlet obstruction caused by an impacted gallstone (Bouveret’s syndrome). Diagn Ther Endosc 2008; 2008: 471512