Case Presentation: A 69-year-old man with coronary artery disease and prior myocardial infarction; cryptogenic cirrhosis; hypertension; end-stage renal disease; and insulin-requiring diabetes mellitus presented with five days of nausea and non-bloody, non-bilious emesis; abdominal distention; and diffuse, cramping abdominal pain. Since the onset of his symptoms, he had continued to pass flatus and formed bowel movements, without melena or hematochezia. He previously had had an upper gastrointestinal hemorrhage, attributed to gastric antral vascular ectasia and a duodenal ulcer.
Abdominal x-rays showed gastric dilation, without evidence of small or large bowel obstruction. Nasogastric decompression resulted in drainage of multiple liters of normal-appearing gastric fluid and improvement of symptoms.
Computed tomographic scan of the abdomen showed a cholecystoduodenal fistula and a large (6.7 x 4.9 cm) calcified gallstone within the proximal duodenum, causing gastric outlet obstruction.
At upper gastrointestinal endoscopy, attempts to fragment and remove the gallstone were incompletely successful. Therefore, exploratory laparotomy and gastrotomy were performed, with complete removal of the residual obstructing stone. A large volume of ascites was drained at surgery.
Unfortunately, the patient’s postoperative course was complicated by persistent drainage of ascitic fluid via surgical drains, followed by sepsis, shock, respiratory failure, and death.
Discussion: Gallstone-related mechanical intestinal obstruction is infrequent, causing only approximately 1-4% of all cases of mechanical bowel obstruction. So-called “gallstone ileus” occurs when a gallstone passes through a cholecystoduodenal or choledochoduodenal fistula and impacts with the gastrointestinal tract, typically at the relatively narrow ileocecal junction, causing distal small bowel obstruction.
Rarer still is Bouveret syndrome – gallstone ileus in the proximal duodenum which causes gastric outlet obstruction. Only approximately 1-3% of cases of gallstone ileus are the result of Bouveret syndrome, the pathophysiology of which is thought to stem from the combination of chronic cholecystitis, intra-abdominal adhesions, gallstone-related pressure necrosis, and eventual cholecystoduodenal fistula formation. Diagnostically, gallstone ileus is often associated with the radiographic “Rigler triad” of bowel obstruction, pneumobilia, and ectopic gallstone.
Because Bouveret syndrome occurs more often in elderly patients, who frequently have multiple co-morbid medical illnesses and increased risk of perioperative morbidity and mortality, an endoscopic treatment approach is usually the first-line intervention, but is frequently unsuccessful. Surgical gallstone removal via gastrotomy or enterotomy is frequently required. Reported mortality with Bouveret syndrome remains sizable, at > 10%.
Conclusions: In the practice of hospital medicine, in collaboration with gastroenterologists and surgeons, hospitalists routinely assess and manage gastrointestinal symptoms and pathology. Hospitalists frequently encounter gallstone-related disease and gastrointestinal obstruction, but rarely does the former directly cause the latter. The purpose of reporting this case is to describe a presentation of Bouveret syndrome, a rare cause of gastric outlet obstruction.