After discussion with the surgical team, it was decided to advance the stone further into the small bowel so surgical removal could be attempted. Using a pediatric colonoscope, the stone was advanced to the proximal jejunum. Repeat CT of the abdomen showed progression of the stone to the mid-jejunum with resolution of the small bowel obstruction (Figure 4). The patient experienced marked improvement in her symptoms after the procedure although surgical retrieval was planned because of the fear of the stone obstructing at the ileocecal valve because of its size. She underwent a laparoscopic enterotomy with removal of the gallstone and did well postoperation. Her diet was slowly advanced, and she was discharged from the hospital 6 days postoperation.
Bouveret syndrome is caused by passage of a large gallstone more than 2.5 cm in size through bilio-gastric and gastroduodenal fistulas into various parts of the digestive tract such as the ileocecal valve (50%–90%).6,7 The proximal jejunum and ileum are less common sites (20%–40%), and the colon, stomach, and duodenum are even less common (<5%).5,8 At least 0.3%–0.5% of patients with gallstones develop ileus.5 Morbidity and mortality are high at 15%–33%.9 Factors that lean toward fistula formation include, but are not limited to, large gallstones, extensive history of biliary disease, recurrent episodes of cholecystitis, female sex, age older than 60 years, peptic ulcer, and tumors.5,8,10
The mechanism of gallstone formation includes inflammatory changes that cause gallbladder wall adherence to the adjacent viscera. These stones increase intraluminal pressure, which results in ischemia of the gallbladder wall, and cause gallstones to erode the wall of the gallbladder to pass into the adjacent viscera, usually the intestine, by forming a fistula. Depending on the size of the gallstone, it can either pass into the feces or get lodged into the intestine, causing intestinal obstruction in 15% of cases.5 Most commonly reported symptoms of intestinal obstruction in various case reports and literature reviews are abdominal pain, distention, nausea, vomiting, fever, and hematemesis in rare cases.11
CT scan is the most sensitive diagnostic test for gallstone ileus; however, it can miss 25% of gallstones if they are radiolucent.10 Other options for investigation are ultrasound and x-ray of the abdomen. Isoattenuating gallstones, which are difficult to distinguish from the surrounding bile, are visualized by magnetic resonance cholangiopancreatography in 15%–25% of cases and endoscopy in 69% of cases.1,11 The literature has reported over 300 cases of Bouveret syndrome.4 A PubMed literature review of 24 cases of Bouveret syndrome and a comprehensive review by Cappell and Davis of 128 cases revealed only 2 cases with successful resolution of intestinal obstruction by an endoscopic approach.3,12,13
Treatment of Bouveret syndrome is either endoscopic or surgical. Endoscopic treatments include mechanical, laser lithotripsy, and electrohydraulic. Electrohydraulic is usually the first choice because of its low risk but is only successful in 10% of cases.5,8,9,11 Endoscopic treatment can cause complications such as migration of the gallstone to the intrathoracic cavity via an esophageal tear if patients have concomitant esophagitis or if the gallstone is large in size.8 Surgical methods including enterolithotomy, which is associated with less morbidity, and duodenotomy, occasionally followed by cholecystectomy and fistula repair, are performed when endoscopic approaches are partially or completely unsuccessful.5,8,9,11
This case is unique among cases of Bouveret syndrome because the patient had an endoscopic resolution of intestinal obstruction via fragmentation of a large gallstone, followed by the pushing of the stone into the jejunum, with subsequent prophylactic enterotomy to prevent risk of distal intestinal obstruction. Repositioning the stone via endoscopy made an otherwise difficult surgical procedure less complicated to prevent mortality and morbidity. It highlights an alternative approach in cases in which stones cannot be removed past the pylorus.
Author contributions: S. Khuwaja wrote and edited the manuscript. A. Azeem, J. Afthinos, and S. Guttman edited the manuscript. BA Semkhayev provided the radiologic images. S. Guttmann is the article guarantor.
Financial disclosure: None to report.
Informed consent was obtained for this case report.
1. Al-Habbal Y, Ng M, Bird D, McQuillan T, Al-Khaffaf H. Uncommon presentation of a common disease—Bouveret's syndrome: A case report and systematic literature review. World J Gastrointest Surg. 2017;9(1):25–36.
2. Iancu C, Bodea R, Al Hajjar N, Todea-Iancu D, Bălă O, Acalovschi I. Bouveret syndrome associated with acute gangrenous cholecystitis. J Gastrointestin Liver Dis. 2008;17:87–90.
3. Bonam R, Vahora Z, Harvin G, Leland W. Bouveret's syndrome with severe esophagitis and a purulent fistula. ACG Case Reports J. 2014;1(3):158–60.
4. Nickel F, Müller-Eschner MM, Chu J, von Tengg-Kobligk H, Müller-Stich BP. Bouveret's syndrome: presentation of two cases with review of the literature and development of a surgical treatment strategy. BMC Surg. 2013;13:33.
5. Shah-Khan S, Vallabh H, Cardinal J, Nasr J. Novel use of an endoscopic suturing device to repair a cholecystoduodenal fistula. ACG Case Rep J. 2017;4:e121.
6. Gencosmanoglu R, Inceoglu R, Baysal C, Akansel S, Tozun N. Bouveret's syndrome complicated by a distal gallstone ileus. World J Gastroenterol. 2003;9(12):2873–5.
7. Sağlam F, Sivrikoz E, Alemdar A, Kamalı S, Arslan U, Güven H. Bouveret syndrome: A fatal diagnostic dilemma of gastric outlet obstruction. Ulus Travma Acil Cerrahi Derg. 2015;21(2):157–9.
8. Martin-Cuesta L, Marco De Lucas E, Pellon R, et al. Migrating intrathoracic gallstone imaging findings. J Thorac Imaging. 2008;23(4):272–4.
9. Patel A, Agarwal S. The yellow brick road of Bouveret syndrome. Clin Gastroenterol Hepatol. 2014;12(8):A24.
10. Englert ZP, Love K, Marilley MD, Bower CE. Bouveret syndrome: Gallstone ileus of the duodenum. Surg Laparosc Endosc Percutan Tech. 2012;22(5):e301–3.
11. Smith Z, Totten J, Hughes A, Strote J. Delayed diagnosis of gastric outlet obstruction from bouveret syndrome in a young woman. West J Emerg Med. 2015;16(1):151–3.
12. Cappell MS, Davis M. Characterization of Bouveret's syndrome: A comprehensive review of 128 cases. Am J Gastroenterol. 2006;101(9):2139–46.
© 2019 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of The American College of Gastroenterology.
13. Lopes C, Lima F, Hartmann A. Bouveret syndrome and pancreatic acinar cell carcinoma. Endoscopy. 2017;49(S 01):E62–3.