Case Presentation: Gallstone ileus is an infrequent cause of bowel obstruction where a gallstone is impacted in the ileum after passing through a fistula between the gallbladder and the gastrointestinal tract. Bouveret syndrome is a rare variant of gallstone ileus where a gallstone passes through a cholecysto-duodenal fistula leading to gastric outlet obstruction. We present a unique case of Bouveret syndrome in a patient who presented with hematemesis and subsequently underwent laparotomy with gastrotomy and gallstone removal. An 89-year-old male with vascular dementia, cholelithiasis, recurrent cholecystitis, and cholangitis, status post ERCP with common bile duct stent placement and biliary sphincteroplasty presented to the ED with hematemesis and fever. Abdominal exam revealed hypoactive bowel sounds with epigastric tenderness. The patient was septic with leukocytosis of 40.1 and new onset hypoxia. Labs were notable for total bilirubin 2.4, conjugated bilirubin 0.7, alkaline phosphatase 117, AST and ALT within normal limits, and lactate 1.8. The patient was promptly managed with intravenous fluids, kept NPO with insertion of a nasogastric tube, and initiated on empiric antibiotics. His computed tomography (CT) abdomen and pelvis revealed a fistulous tract between the gallbladder and the first to second portion of the duodenum with an obstructing 2.5-centimeter gallstone in the second to third portion of the duodenum. The stomach was markedly distended and fluid-filled. Both gastroenterology and general surgery teams were consulted for the complex decision of endoscopic gallstone removal versus laparotomy. Given the stone’s size and the patient’s extensive comorbidities, an exploratory laparotomy was performed. The stone was successfully removed via gastrotomy through the pylorus to the duodenum. One day post-op, the patient’s condition unfortunately deteriorated. He showed worsening leukocytosis and progressed to septic shock. He was transitioned to comfort measures only per his family’s wishes.
Discussion: Bouveret syndrome is a rare diagnosis associated with a high rate of morbidity and mortality. Presenting symptoms typically include nausea, vomiting, abdominal pain, and less commonly hematemesis or melena, with objective findings of abdominal distention, tenderness and dehydration. The Rigler triad of bowel obstruction, pneumobilia and gallstone may be seen on abdominal x-ray, though CT scan is preferred as it shows the fistulous track in addition to the stone. The presentation may be subtle, but Bouveret syndrome is important to suspect early as prompt surgical or endoscopic management is often indicated. Endoscopic nets or baskets are often utilized for smaller gallstones. Larger stones greater than two centimeters often require either open surgery as described above or endoscopy with mechanical, laser, or shockwave lithotripsy.
Conclusions: Physicians should have a high degree of suspicion for Bouveret Syndrome in patients presenting with gastric outlet obstruction. While unusual, the diagnosis portends high mortality and requires a prompt interdisciplinary discussion amongst internists, endoscopists, and surgeons. The size of the stone, procedural expertise, and the patient’s comorbidities should all be considered to determine the most appropriate procedure modality for each patient.