Introduction: This is a case of a 59 year old female with Bouveret’s syndrome. An initial endoscopic approach to management is described. Gallstone ileus occurs when a gallstone passes from a cholecystoduodenal fistula or a choledochoduodenal fistula into the GI tract and causes obstruction, usually at the ileocecal valve. Bouveret’s syndrome is a variant of gallstone ileus where the gallstone lodges in the duodenum or pylorus causing a gastric outlet obstruction.
Case: The patient presented to the emergency department with a 3-day history of nausea and vomiting. Liver function tests were normal, but a CT revealed pneumobilia with evidence of cholecystitis and cholecystoduodenal fistula. There was a large obstructing gallstone in the 3rd portion of the duodenum. An unsuccessful attempt was made at endoscopic retrieval using multiple modalities including net, snare, stone basket, balloons, and biopsy forceps. Combination modalitiesincluding a dual channel scope with two balloons and another attempt using a snarewith rat-tooth forceps for manipulation and stabilization of the stone were also unsuccessful. The smooth, calcified exterior surface would not allow purchase of the jaws of the forceps.The length of the stone prohibited passage of guidewires and balloons alongside the duodenum. She then underwent a one-stage procedure including enterolithotomy and cholecystectomy with repair of the cholecystoduodenal fistula. The stone at laparotomy had migrated approximately 30cm into the jejunum and was removed via an enterotomy. The gallbladder was removed and the fistula repair buttressed with an omental patch and fibrin glue. The gallstone was measured at 8×4 cm. The patient has done well in the post-operative period.
Discussion: Gallstone ileus is a rare complication of cholelithiasis. Bouveret’s syndrome is a rare variant, accounting for 1-3% of cases of gallstone ileus. It is diagnosed radiographically via CT scan. There is some controversy regarding the operative treatment of Bouveret’s syndrome. The primary goal of therapy is to relieve the obstruction by removing the stone. If the patient will tolerate it, the gallbladder should be removed and the fistula repaired. Newer techniques involving endoscopic retrieval and electrohydraulic lithotripsy (EHL) should also be considered; but this will depend on the stability of the patient and the available equipment and expertise of the team caring for the patient. There is no documented endoscopic experience using EHL in the duodenum and risk of perforation is a consideration. Additionally, large fragments of the stone could have resulted in distal obstruction. The stone in this case was too large for any of our available endoscopic modalities. Given the concern for perforation due to pressure necrosis, she was taken to the operating room for definitive management.
Conclusion: Bouveret’s syndrome is an uncommon variation of a rare disease. The endoscopic and surgical management of this processare important to keep in mind and may be evolving as endoscopic therapies improve.
Program Number: P400