Development of a duodenal gallstone ileus with gastric outlet obstruction (Bouveret syndrome) four months after successful treatment of symptomatic gallstone disease with cholecystitis and cholangitis: a case report

Abstract

IntroductionCases of gallstone ileus account for 1% to 4% of all instances of mechanical bowel obstruction. The majority of obstructing gallstones are located in the terminal ileum. Less than 10% of impacted gallstones are located in the duodenum. A gastric outlet obstruction secondary to a gallstone ileus is known as Bouveret syndrome. Gallstones usually enter the bowel through a biliary enteral fistula. Little is known about the formation of such fistulae in the course of gallstone disease.Case presentationWe report the case of a 72-year-old Caucasian woman born in Germany with a gastric outlet obstruction due to a gallstone ileus (Bouveret syndrome), with a large gallstone impacted in the third part of the duodenum. Diagnostic investigations of our patient included plain abdominal films, gastroscopy and abdominal computed tomography, which showed a biliary enteric fistula between the gallbladder and the duodenal bulb. Our patient was successfully treated by laparotomy, duodenotomy, extraction of the stone, cholecystectomy, and resection of the fistula in a one-stage surgical approach. Histopathological examination showed chronic and acute cholecystitis, with perforated ulceration of the duodenal wall and acute purulent inflammation of the surrounding fatty tissue. Four months prior to developing a gallstone ileus our patient had been hospitalized for cholecystitis, a large gallstone in the gallbladder, cholangitis and a small obstructing gallstone in the common biliary duct. She had been treated with endoscopic retrograde cholangiopancreatography, endoscopic biliary sphincterotomy, balloon extraction of the common biliary duct gallstone, and intravenous antibiotics. At the time of her first presentation, abdominal ultrasound and endoscopic examination (including esophagogastroduodenoscopy and endoscopic retrograde cholangiopancreatography) had not shown any evidence of a biliary enteral fistula. In the four months preceding the gallstone ileus our patient had been asymptomatic.ConclusionIn patients known to have gallstone disease presenting with symptoms of ileus, the differential diagnosis of a gallstone ileus should be considered even in the absence of preceding symptoms related to the gallbladder disease. Gallstones large enough to cause intestinal obstruction usually enter the bowel by a biliary enteral fistula. During the formation of such a fistula, patients can be asymptomatic.

Recurrent Gallstone Ileus in an Elderly Patient With Significant Co-Morbidity

“…In the diagnostics, history of recent gallstone disease exacerbation should alert attention. However, as in our case, the formation of fistula itself can occur during clinically silent period after the exacerbation (Giese et al, 2010). CT and ultrasonography can provide valuable information (Giese et al, 2010).…”

“…The presence of gallstones can lead to diverse complications. Biliary enteric fistula develops in 2-3% of patients with cholecystolithiasis and recurrent cholecystitis (Roslyn et al, 1987;Giese et al, 2010). If choledochoduodenal fistula has developed, the stones can pass into the small intestines and occasionally become trapped causing ileus.…”

“…If choledochoduodenal fistula has developed, the stones can pass into the small intestines and occasionally become trapped causing ileus. Gallstone ileus accounts for 1-4% of mechanical bowel obstruction and in aged persons (older than 65 years) -for 25% of non-strangulated small bowel obstruction cases (Giese et al, 2010). Due to the sedimentation of intestinal content, gallstones can increase in diameter and more frequently impact in the distal part of small intestine (Giese et al, 2010).…”

“…Gallstone ileus accounts for 1-4% of mechanical bowel obstruction and in aged persons (older than 65 years) -for 25% of non-strangulated small bowel obstruction cases (Giese et al, 2010). Due to the sedimentation of intestinal content, gallstones can increase in diameter and more frequently impact in the distal part of small intestine (Giese et al, 2010). The impacted stone is located in the terminal ileum in 50-75%, proximal ileum and jejunum in 20-40%, and in duodenum in 10% cases.…”

Gall stone ileus- a rare cause of intestinal obstruction: a case report and review of literature

“…Fistula formation is a complication of 2-3% of all cases of calculus cholecystitis. 4 The clinical features of Gall stone ileus are similar to that of mechanical obstruction. 5 Abdominal pain and vomiting are the most common clinical presentations.…”