Bouveret’s Syndrome: A Case Series and Literature Review on a Gallstone Disease Causing Gastric Outlet Obstruction

Abstract

IntroductionBouveret's syndrome refers to a gastric outlet obstruction due to the impaction of a large gallstone following retrograde migration via a bilio-duodenal fistula. Although no clear management guideline has been formulated, different treatment modalities have been described, including endoscopic stone removal using classical endoscopic devices, like snares and forceps, or fragmentation of stones with new devices, such as lasers and extracorporeal shockwave lithotripsy (ESWL). ResultsThis case series reports six patients who have been diagnosed with Bouveret's syndrome and have presented with interesting radiological and endoscopic findings. The report is followed by a literature review, including diagnostic and management options for this rare condition. DiscussionCholelithiasis is a common condition occurring in the general population and may develop rare complications such as cholecystoduodenal fistula. Bouveret's syndrome presents with a clinical picture similar to that of gastric outlet obstruction, and laboratory findings are often consistent with an obstructive jaundice picture. The use of endoscopic treatment with a range of different lithotripsy modalities has been described to manage this condition. ConclusionThe diagnosis of Bouveret's syndrome is made after performing appropriate imaging studies. The first-line management option is endoscopic treatment. If this fails, surgical intervention is recommended.

Rare presentation of gastric outlet obstruction with jejunal impaction of gall stones-the Bouveret’s syndrome

“…8 As a result, with gradually increasing pressure and necrosis of the chole cysto-duodenal/ gastric wall, gall stones erode into the enteric lumen, which can subsequently migrate proximally or distally, the resulting gastric outlet obstruction is known as Bouveret's syndrome, on radiological imaging has a triad of, the air in biliary radicles, gall stones and small bowel ileus known as Rigler's triad, however, classical Rigler's triad is present in only 40% of patients only. 2 The patients present with clinical complaints of pain abdomen, vomiting multiple episodes with or without features of intestinal obstruction, due to various ages of presentation, a patient may be symptomatic/asymptomatic with a previous history of biliary colicky abdominal pain, in advanced age it may also mimic symptoms of distal gastric malignancy, the patients may present with aspirational pneumonia and other age-related comorbidities. 9 On patient's presentation in emergency features of dehydration and dyselecrolytemia and Ph must be corrected.…”

“…1 Gallstones can present as recurrent biliary colicky pain, acute/chronic cholecystitis, obstructive jaundice with choledocholithiasis with or without severe sepsis and cholangitis, acute/recurrent gallstone induced pancreatitis, Mirizzi's syndrome, gallstone ileus, and gallbladder malignancies. 2 Among them, recurrent biliary pain/acute cholecystitis are the most common complications while gallstone ileus is a rare complication with an incidence of 0.3-0.5% and 1-4% of the causes of dynamic intestinal obstruction. 3 Bouveret's syndrome is a rare cause of gastric outlet obstruction caused due to gallstone complications with impaction of multiple stones/large gall stones in the duodenal bulb after traversing through a billion-duodenal fistula.…”

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

“…Due to the gallbladder's posterior relation with the duodenum, the bilioenteric fistula develops most frequently to the duodenal bulb, creating a pathway for large gallstones, often >2.5 cm in diameter, to migrate to the intestinal lumen and result in an intestinal obstruction, known as gallstone ileus [3]. However, when the fistula develops and a gallstone obstructs the gastric outlet, a proximal variant of gallstone ileus occurs, resulting in Bouveret's syndrome [1][2][3]. The presented case reports two unique complications of biliodigestive fistulas occurring at the same time in a patient with gallstone disease.…”

“…During their lifetimes, 20% of patients with gallstones will develop symptoms and different complications. 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 [ 1 , 2 ]. Due to the gallbladder’s posterior relation with the duodenum, the bilioenteric fistula develops most frequently to the duodenal bulb, creating a pathway for large gallstones, often >2.5 cm in diameter, to migrate to the intestinal lumen and result in an intestinal obstruction, known as gallstone ileus [ 3 ].…”

Bouveret Syndrome: A Rare Case of Gastric Outlet Obstruction Caused by an Impacted Gallstone

“…Subsequently, the gallstone may pass through the fistula and lodge in the duodenum or pylorus, causing gastric outlet obstruction. The impacted stone acts as a mechanical barrier, obstructing the passage of food and gastric contents [ 2 ].…”