St. Luke's University Hospital Bethlehem, PA, United States
Subin G. Chirayath, DO, Sagar V. Mehta, MD, Loveleen Sidhu, MD, Ronak Modi, MD, Ayaz Matin, MD St. Luke's University Hospital, Bethlehem, PA
Introduction: Bouveret's syndrome is a rare manifestation of gallstone disease marked by the formation of a fistula between the gallbladder and either the stomach or the small bowel. We discuss two cases of Bouveret’s Syndrome resulting in the formation of a cholecystogastric and cholecystoduodenal fistula.
Case Description/Methods: Our first case is an 89-year-old male presenting with epigastric and chest pain. CT of the abdomen showed a collapsed gallbladder with left-sided pneumobilia, no gastric outlet obstruction and a large gallstone located in the duodenum (Fig. 1). On endoscopy the stone was identified in the post-pylorus region with a cholecystoduodenal fistula (Fig. 2). The stone was successfully fragmented using a biliary electrohydraulic auto-lithotripter. Our second case is a 58-year-old male presenting with generalized abdominal pain. CT scan showed a decompressed gallbladder, pneumobilia, a large gallstone in the stomach (Fig. 3). Upper endoscopy confirmed the presence of a cholecystogastric fistula along the greater curvature of the stomach however the gallstone was no longer present (Fig. 4). Patient improved with treatment of acute gallstone pancreatitis and subsequently discharged with a plan for elective cholecystectomy.
Discussion: BS is a rare form of gallstone ileus defined by the location of the fistula that forms between the gallbladder and the gastrointestinal tract. Gallstone ileus is responsible for 1-4% of cases of intestinal obstruction, with BS only accounting 1-3% of those cases.1 Interestingly, though BS is more common in older females, both of our patients were middle to older aged men. All patients with suspected or confirmed BS should undergo endoscopy, as it can confirm the location of the gallstone or fistula in approximately 69% of cases and allows for therapeutic intervention.2 Endoscopy can treat gallstones with lithotripsy, which involves obliterating gallstones using a variety of modalities including mechanics (ML), electrohydraulics (EHL), lasers or extracorporeal shockwaves (ESWL). Our first patient was successfully treated with EHL. Prompt intervention with advances in endoscopic modalities have been instrumental in decreasing morbidity and mortality in Bouveret's Syndrome.
References: 1. Baharith et. al. Bouveret Syndrome: When There Are No Options. Canadian Journal of Gastroenterology and Hepatology 2015; 29(1): 17-18. 2. Pickhardt et. al. CT, MR cholangiopancreatography, and endoscopy findings in Bouveret's syndrome. AJR Am J Roentgenol. 2003; 180(4):1033-5.
Figure: Figure 1: CT abdomen pelvis with evidence of gallstone in the 1st to 2nd portion of the duodenum (indicated by red circle). Figure 2: Endoscopic appearance of impacted large gallstone at the post-pylorus region. Figure 3: CT abdomen pelvis showing gallstone present in the stomach (indicated by red circle) with evidence of pneumobilia. Figure 4: Endoscopic evidence of cholecystogastric fistula in the greater curvature of the stomach (indicated by red circle).
Disclosures:
Subin Chirayath indicated no relevant financial relationships.
Sagar Mehta indicated no relevant financial relationships.
Loveleen Sidhu indicated no relevant financial relationships.
Ronak Modi indicated no relevant financial relationships.
Ayaz Matin indicated no relevant financial relationships.
Subin G. Chirayath, DO, Sagar V. Mehta, MD, Loveleen Sidhu, MD, Ronak Modi, MD, Ayaz Matin, MD. P0673 - The Tale of Two Fistulas: A Comparison of Bouveret’s Syndrome Manifesting as a Cholecystogastric and Cholecystoduodenal Fistula, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.
