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Bouveret’s Syndrome: Management and Strategy of a Rare Cause of Gastric Outlet Obstruction
Abstract
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... Gallstone ileus is a rare complication of cholecystitis that occurs in 0.5% of cases [1]. It usually occurs because of a cholecystoenteric fistula, allowing the passage of a large stone in the intestine [2,3]. It can happen after sphincterotomy as well, but remains an uncommon complication. ...
... A plain abdominal radiography can show a calcified mass with obstructive signs. Classically, the Rigler's triad is the presence of an aerobilia, a mechanical bowel obstruction and an ectopic gallstone [2]. In case of doubt, a computed tomography is usually performed. ...
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... Articles comprised 161 case reports , 13 reviews [164][165][166][167][168][169][170][171][172][173][174][175][176] , 23 images reports (radiological and clinical images and 11 letters to the editor [199][200][201][202][203][204][205][206][207][208][209] , as illustrated in ( Figure 1F). ...
Aim:
To investigate and summarise the current evidence surrounding management of Bouveret's syndrome (BS).
Methods:
A MEDLINE search was performed for the BS. The search was conducted independently by two clinicians (Yahya AL-Habbal and Matthew Ng) in April 2016. A case of BS is also described.
Results:
A total of 315 articles, published from 1967 to 2016, were found. For a clinically meaningful clinical review, articles published before 01/01/1990 and were excluded, leaving 235 unique articles to review. Twenty-seven articles were not available (neither by direct communication nor through inter-library transfer). These were also excluded. The final number of articles reviewed was 208. There were 161 case reports, 13 reviews, 23 images (radiological and clinical images), and 11 letters to editor. Female to male ratio was 1.82. Mean age was 74 years. Treatment modalities included laparotomy in the majority of cases, laparoscopic surgery, endoscopic surgery and shockwave lithotripsy.
Conclusion:
There is limited evidence in the literature about the appropriate approach. We suggest an algorithm for management of BS.
... Performing cholecystectomy and fistula closure in the same surgical procedure is associated with a morbidity and mortality of 35%, vs. 12% in those patients in whom only lithiasis is removed. Additionally, if we consider that a cholecystoduodenal fistula can work as a biliodigestive anastomosis, and that the fistulous tract usually closes spontaneously (especially if there is no residual lithiasis), cholecystectomy and fistula closure can be assessed subsequently in each case, as a possible further step [9,10]. In our case, the patient was operated on urgently through median laparotomy, and the gallstone was removed through gastrotomy, after mobilization from the duodenum ( Figure 5). ...
Bouveret Syndrome (BS) is a rare type of gallstone ileus in which a gallstone enters the intestinal tract via a cholecystoenteric fistula and is lodged in the duodenum or the stomach. It should be considered in any patient who presents with pneumobilia without recent endoscopic retrograde cholangiopancreatography (ERCP) or biliary surgery. Morbidity and mortality rates have decreased in recent years, but still remain high, at 25%, and may be related to the advanced age of the typical patient and their resulting comorbidities, as well as to diagnostic delay. Endoscopy is preferred as the first therapeutic option, but is frequently unsuccessful, and surgery is often required. We present a case report of a patient with symptoms of gastric outlet obstruction, with interesting radiological findings and successful surgical treatment after failure of endoscopic techniques.
... Despite multiple attempts, however, EGD was nondiagnostic in this setting as we were unable to pass the pinpoint pylorus. In this setting of complicated Bouveret's syndrome, open surgery remains the treatment option of choice [9]. Surgical options include laparotomy, longitudinal duodenotomy, stone retrieval, and transverse closure of duodenotomy. ...
We describe a case of a 63-year-old male with complicated Bouveret's syndrome, both in its presentation and in its management. Bouveret's syndrome is a rare cause of gastric outlet obstruction resulting from mechanical obstruction from gallstones at the pyloroduodenal segment. As Bouveret's syndrome can be a diagnostic and therapeutic challenge for clinicians, we aim to identify clinical and radiologic pearls that can lower the threshold for the diagnosis of Bouveret's syndrome.
Background and goals:
Bouveret syndrome is characterized by gastroduodenal obstruction caused by an impacted gallstone. Current literature recommends endoscopic therapy as the first line of intervention despite significantly lower success rates compared with surgery. The lack of treatment efficacy studies and the paucity of clinical guidelines contribute to current practices being arbitrary. The aim of this systematic review was to identify factors that predict outcomes of endoscopic therapy. Subsequently, a predictive tool was devised to predict the success of endoscopic therapy and recommendations were proposed to improve current management strategies of impacted gallstones in the upper gastrointestinal tract.
Methods:
A systematic search of PubMed, Medline, Cochrane, and Scopus was performed for articles that contained the terms "Bouveret syndrome," "Bouveret's syndrome," "gallstone" AND "gastric obstruction" and "gallstone" AND "duodenal obstruction" that were published between January 1, 1950 to April 15, 2018. Articles were reviewed by 3 reviewers and raw data collated. χ and Kolmogorov-Smirnov tests were used to test associations between predictors and endoscopic outcomes. A logistic regression model was then used to create a predictive tool which was cross validated.
Results:
Failure of endoscopic therapy is associated with increasing gallstone length (P<0.0001) and impaction in the distal duodenum (P<0.05). Using multiple endoscopic modalities is associated with better success rates (P<0.05). The novel predictive tool predicted success of endoscopic therapy with an area under the receiver operating characteristic score of 0.86 (95% confidence interval: 0.79-0.94).
Conclusion:
In Bouveret syndrome, a selective approach to endoscopic therapy can expedite definitive treatment and improve current management strategies.
Gallstone ileus is rare condition, accounts for 1.4-6% of all obstructing ileus. It complicates 0.4-1.5% of all cases of cholelithiasis. Symptoms of gallstone obstruction are vague, usually mimic biliary colic. Authors present two cases of patient with gallstone ileus first diagnosed for nonspecific symptoms in alimentary tract. Both patients were operated. In the first case enterolithotomy alone was made. The post-operative course was uneventful. In the second case definitive procedure of cholecystectomy and fistula closure along with enterolithotomy was made. A month later abscess in the site of removed gallbladder was conservative treated with good result.
Bouveret's syndrome is a rare type of gallstone ileus in which a gallstone enters the intestinal tract via a cholecystoenteric fistula and is lodged in the duodenum or the stomach. Since the first description by León Bouveret in 1896, fewer than 200 cases have been described in the worldwide literature. Mortality is high, at 25%, but may be related to the advanced age of the typical patient and comorbidities, as well as diagnostic delay. Diagnosis may be made with radiological (abdominal X-ray, ultrasound, computed tomography or magnetic resonance imaging) and endoscopic techniques. Endoscopy is preferred as the first therapeutic option but is frequently unsuccessful and surgery is often required. We present the case of a patient admitted to hospital with a history of vomiting after eating and epigastric pain. The management of this rare cause of gastric outlet obstruction is discussed.
Gastric Outlet Obstruction (GOO) due to impaction of a gallstone in the duodenum after migration through a bilioduodenal fistula is known as Bouveret's syndrome. Its clinical symptoms are entirely vague and nonspecific. Because of its rarity, insidiousness and unpredictable symptomatology, Bouveret's syndrome is never thought of in the differential diagnosis as aetiology of gastric outlet obstruction. Recent advances in fiberoptics technology, advent of modern imaging modalities and minimally-invasive techniques like endoscopy and laparoscopy has brought a great revolution in the management of Bouveret's syndrome and have tremendously decreased morbidity and mortality associated with this rare clinical entity.
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Gastric outlet obstruction secondary to the impaction of large biliary stones into the duodenum (Bouveret's syndrome) is a well-known complication of biliary lithiasis, most often requiring surgical intervention. We report a case of successful endoscopic removal of a large stone impacted in the duodenal bulb by means of mechanical lithotripsy.
Gastric outlet obstruction as a result of gallstone (Bouveret syndrome) is a rare but serious complication of cholelithiasis. In many cases, surgery has been conducted for treatment. In recent years, minimal invasive treatment modalities (e.g. shockwave lithotripsy) have been shown to be effective in some of those patients. Laserlithotripsy has so far been described in two cases with a Rhodamine-6G dye laser. We present the case of a 90-year-old woman with duodenal obstruction due to a huge gallstone. The patient was referred to our hospital because attempts at endoscopic extraction and extracorporeal shockwave lithotripsy had failed. The man was treated successfully in just one session with a new cost-efficient frequency doubled doublepulse Nd:YAG laser (FREDDY) using a total of 5726 laser pulses (120 mJ pulse energy, 10 Hz pulse repetition rate) and recovered rapidly. Laserlithotripsy can be considered an effective non-invasive therapeutic alternative to surgical treatment in Bouveret's syndrome, especially in old or high-risk patients.
Two patients with gastric outlet obstruction caused by a gallstone were treated by endoscopic lithotripsy. All fragments of significant size were removed orally, except for one that was left in the stomach in the first patient.
This fragment caused a recurrent ileus after initial clinical improvement. The other patient remained clinically well after hospital discharge.
Gastric outlet obstruction caused by duodenal impaction of a large gallstone migrated through a cholecystoduodenal fistula has been referred as Bouveret's syndrome. Endoscopic lithotomy is the first-step treatment, however, surgery is indicated in case of failure or complication during this procedure.
We report herein an 84-year-old woman presenting with features of gastric outlet obstruction due to impacted gallstone. She underwent an endoscopic retrieval which was unsuccessful and was further complicated by distal gallstone ileus. Physical examination was irrelevant.
Endoscopy revealed multiple erosions around the cardia, a large stone in the second part of the duodenum causing complete obstruction, and wide ulceration in the duodenal wall where the stone was impacted. Several attempts of endoscopic extraction by using foreign body forceps failed and surgical intervention was mandatory. Preoperative ultrasound evidenced pneumobilia whilst computerized tomography showed a large stone, 5 cm x 4 cm x 3 cm, logging at the proximal jejunum and another one, 2.5 cm x 2 cm x 2 cm, in the duodenal bulb causing a closed-loop syndrome. She underwent laparotomy and the jejunal stone was removed by enterotomy. Another stone reported as located in the duodenum preoperatively was found to be present in the gallbladder by intraoperative ultrasound. Therefore, cholecystoduodenal fistula was broken down, the stone was retrieved and cholecystectomy with duodenal repair was carried out. She was discharged after an uneventful postoperative course.
As the simplest and the least morbid procedure, endoscopic stone retrieval should be attempted in the treatment of patients with Bouveret's syndrome. When it fails, surgical lithotomy consisting of simple enterotomy may solve the problem. Although cholecystectomy and cholecystoduodenal fistula breakdown is unnecessary in every case, conditions may urge the surgeon to perform such operations even though they carry high morbidity and mortality.
Thirty-seven patients (33 women and four men, median age 78 years) were operated on for gallstone ileus over a 12-year period with a median follow-up of 6.2 years. Twenty-three patients (62 per cent) had serious concomitant diseases. Plain abdominal radiographs performed at admission were diagnostic in only 17 patients (46 per cent) and other procedures such as ultrasonography, gastrointestinal contrast studies and computed tomographic scan were required in ten patients (27 per cent). The diagnosis was made before operation in 27 patients (73 per cent) but in only 17 (46 per cent) at admission. Obstructing stones were located in the terminal ileum in 27 patients (73 per cent), in the proximal ileum or jejunum in five (14 per cent), in the duodenum in two (5 per cent), and in the colon in three (8 per cent). In six instances (16 per cent), more than one stone was involved. Cholecystduodenal fistula was the most frequent fistula type (n = 25, 68 per cent), followed by cholecystcolonic (n = 2, 5 per cent) and cholecystduodenocolonic (n = 2, 5 per cent) types. The site of the fistula was not established in the other eight instances. A one-stage procedure consisting of the removal of the impacted stone, fistula repair and cholecystectomy was performed in eight patients, two of whom died. A second group of six patients underwent a two-stage procedure consisting of enterolithotomy followed by elective biliary surgery, with no mortality. Removal of impacted stones was the only surgical treatment in the remaining 23 patients, with five deaths. Operative mortality and morbidity rates associated with the initial procedure did not differ significantly among the three therapeutic groups, which were comparable in terms of patient age, associated concomitant diseases and APACHE II score. However, later biliary complications were prominent in patients treated only by enterolithotomy. These results support the view that a one-stage procedure is, when feasible, a valid option and may be the procedure of choice. When local or surgical conditions argue against a one-stage procedure, biliary surgery at a second stage should be considered, if residual stones are present. In poor risk patients, non-operative methods should be considered.
Gallstone has rarely been described as a cause of gastrointestinal obstruction. However, the relative incidence of gallstone ileus increases significantly with age. The gastric outlet is very seldom the location of obstruction by a gallstone. The diagnosis of this condition is not difficult. Nevertheless, if treatment is delayed, high morbidity and mortality rates result. Comprehensive treatment aims to relieve the obstruction, to close the biliodigestive fistula and to prevent further gallbladder complications. The surgeon who deals with this type of illness should tailor the treatment plan according to the age, general condition, and intraoperative findings of the individual patient. This paper presents a case report of an 88-year-old woman with gastric outlet obstruction caused by a gallstone.
Duodenal impaction of a gallstone after its migration through a cholecystoduodenal fistula is an uncommon cause of gallstone ileus described as Bouveret's syndrome. Surgical treatment is recommended, but the morbidity and mortality rates are nearly 60% and 30%, respectively. To reduce these rates using improved endoluminal surgery, a laparoscopically assisted intraluminal gastric surgery could be considered. A 74 year-old woman was admitted with typical Bouveret's syndrome. An intraluminal gastric laparoscopy was performed. The large stone impacted in the first duodenum was removed through the pylorus and pulled into the stomach. After its mechanical fragmentation, the stone was extracted with a sterile retriever bag through the main trocar. In the case of Bouveret's syndrome, treatment of the duodenal obstruction is mandatory. Surgical treatment of the cholecystoduodenal fistula still is controversial. We never perform a one-stage procedure, and we reserve a biliary operation for the patient who remains symptomatic. In this way, laparoscopically assisted intraluminal gastric surgery with transpyloric extraction of the stone can be a safe and interesting approach for this type of pathology.
An 84-year-old woman with severe dementia, who resides at anursing home, presented with a 4-day history of persistentnausea and vomiting bilious fluids, associated anorexia and milddehydration. Her other medical problems included perniciousanaemia. Full blood examination, urnea, electrolytes and creatinineand liver function tests (LFT) were unremarkable. AbdominalX-ray revealed a distended stomach, pneumobilia and two largeradio-opaque gallstones.To further elucidate the cause of the gastric outlet obstruction,abdominal computed tomography (CT) was ordered, whichdemonstrated a large calculus in the second part of the duodenumcausing distention of the proximal duodenum and stomach. A second large gallstone was found in the lumen of the gall-bladder. Due to the degree of dementia and the patient’s mentalstate, no oral contrast was given.The patient proceeded to surgery the following day. AKocher’s incision was made and duodenotomy performed forthe second part of the duodenum. This was followed by removal ofa 5cm duodenal stone, closure of the fistula with 3/0 polydiox-anone suture (PDS) and an open cholecystectomy to remove the6cm gallstone. The procedure was completed with a retrocolicgastroenterostomy given the extent of the duodenotomy.The inpatient hospital stay was unremarkable. The patient was commenced on oral fluids on day 4, solids on day 5 anddischarged on day 10.
Bouveret's syndrome, which is gastric outlet obstruction caused by a gallstone in the duodenum or pylorus, is a very rare complication of gallstone disease. It occurs most commonly in women (65%), with a median age of 68.6 years. This disorder is usually treated by surgery, but it has also been successfully treated by endoscopy, with or without extracorporeal shock wave lithotripsy. The mortality rate has improved to 12% in recent years. Herein we report the case of a 76-year-old woman with Bouveret's syndrome, and review the literature on this unusual entity.
An 83-year-old woman presented with a history of acute abdominal pain, nausea, and vomiting of approximately 24 hours’ duration. The pain was localized to the epigastrium and seemed to improve after she vomited. Surgical history included a laparotomy five months earlier with omental patch repair of a perforated duodenal ulcer. Abdominal x-rays and computed axial tomography (CAT) scan of the abdomen from that admission showed a large gallstone in the gallbladder (Figs. 1 and 2). On this admission, abdominal x-rays showed a gas-filled, distended stomach and proximal duodenum. In addition, the gallstone previously seen in the gallbladder had migrated to the left of the midline (Fig. 3). A CAT scan of the abdomen confirmed the presence of a large gallstone within the fourth portion of the duodenum as well as a proximally distended duodenum (Fig. 4). During surgery, we found the omentum to be densely adhered to the undersurface of the liver, thus precluding assessment of the gallbladder. The gallstone was identified at the root of the transverse mesocolon in the fourth portion of the duodenum, just medial to the ligament of Trietz. The stone was easily milked into the proximal jejunum, where an enterolithotomy was performed. After surgery, the patient was briefly monitored in the intensive care unit for respiratory distress and otherwise had an uneventful recovery. She did well during the year after surgery. Gallstone ileus is a rare manifestation of gallstone disease and accounts for approximately 1% to 3% of all cases of intestinal obstruction. Impaction of the stone most commonly occurs in the distal ileum (90%) and much less frequently in the colon (3% to 8%) or duodenum (3%) [1]. Gastric outlet obstruction secondary to a gallstone has been termed “Bouveret’s syndrome,” which acknowledges its original description by Bouveret in 1896 [1]. Although a diagnosis of gallstone ileus is often difficult to make on clinical grounds, the diagnosis can often be confirmed before surgery using various radiographic investigations. In approximately 50% of cases, the identification of air in the biliary tree, a mechanical bowel obstruction, and an ectopic gallstone (Rigler’s Triad) on abdominal x-ray is diagnostic [1,2]. Using additional investigational modalities—such as contrast studies, CAT scan, and endoscopy—increases the preoperative diagnostic yield to nearly 75% [2,3]. The management of gallstone ileus is primarily surgical and depends on the anatomic location of the obstruction as well as the findings during surgery. For patients presenting with Bouveret’s syndrome, the surgical options include (1)
The aim of the study was to characterize the clinical presentation, evaluation, and therapy of Bouveret's syndrome, by comprehensively reviewing all the identified previously reported cases, to facilitate early diagnosis and thereby to improve the prognosis.
Relevant articles were identified by MEDLINE computerized searches, by consultation with all available reference books, and by review of the first author's teaching files. A new case in which the diagnosis of Bouveret's syndrome was missed at esophagogastroduodenoscopy (EGD)--despite endoscopic findings of gastric outlet obstruction caused by a hard, nonfleshy, and convex pyloric mass--prompted this review.
Review of 128 reported cases identified syndromic characteristics. Patients on average were 74.1 +/- 11.1 (SD) yr old. The female-to-male sex ratio was 1.86. Prominent symptoms were nausea and vomiting in 87%, abdominal pain in 71%, hematemesis in 15%, recent weight loss in 14%, and anorexia in 13% of patients. Prominent signs were abdominal tenderness in 44%, signs of dehydration in 31%, and abdominal distention in 26% of patients. Endoscopy revealed gastroduodenal obstruction in nearly all cases, but identified the obstructing stone in only 69%. Abdominal ultrasound or computerized tomography was diagnostic in about 60% of cases.
The following endoscopic findings are suggestive of Bouveret's syndrome: a dilated stomach containing old digested food from gastrointestinal obstruction together with a hard and nonfleshy mass at the obstruction. These endoscopic findings, in the setting of the currently reported characteristic epidemiologic and clinical findings, should strongly suggest this syndrome. Abdominal ultrasound or computerized tomography is recommended to confirm and extend the endoscopic diagnosis.