Mayo School of Graduate Medical Education Jacksonville, FL, United States
Award: Presidential Poster Award
Aman S. Bali, MD1, David DiSantis, MD2, Frank J. Lukens, MD2, Paul T. Kroner, MD, MSc2 1Mayo School of Graduate Medical Education, Jacksonville, FL; 2Mayo Clinic, Jacksonville, FL
Introduction: Bouveret syndrome is a rare form of a gallstone ileus caused by impaction of a gallstone at the pylorus or proximal duodenum causing gastric outlet obstruction (GOO). Here we present the case of a man presenting with clinical and imaging evidence of GOO who was diagnosed with Bouveret syndrome despite no obvious gallstone on plain films or CT imaging.
Case Description/Methods: A 73-year-old man with a recent history of complicated cholecystitis 2 months prior requiring percutaneous cholecystostomy tube (PCT) complicated by cholecystoduodenal fistula (PCT subsequently removed) presented to the emergency room with acute-onset nausea, vomiting, and intolerance of oral intake for 1 day. Physical exam showed no abdominal tenderness and laboratory studies showed mild leukocytosis and transaminitis. Abdominal plain film showed no abnormal findings and CT scan reported a decompressed, thickened gallbladder containing gas with cholecystoduodenal fistula along with gaseous distention of the stomach concerning for possible GOO (Panel A). A nasogastric tube was placed for decompression and barium upper gastrointestinal (GI) series was performed. While invisible on CT, the GI series revealed a large, ovoid filling defect in the proximal duodenal lumen, concerning for a radiolucent gallstone (Panel B). Endoscopic retrograde cholangiopancreatography was subsequently performed which revealed a 4 cm post-pyloric impacted gallstone (Panel C). Conventional large snares and basket mechanical lithotripters were unable to grasp the large stone so electrohydraulic lithotripsy (EHL) was used to fragment the stone into smaller pieces (Panels D). Despite EHL, peri-pyloric tissue edema precluded stone extraction (Panel E). However, the smaller size of the fragments permitted passage into the duodenum where a 4 x 8 cm Roth Net retriever was used to extract most fragments (Panel F). The patient subsequently underwent successful laparoscopy with cholecystectomy and takedown of cholecystoduodenal fistula.
Discussion: This clinical vignette highlights an unusual case of Bouveret syndrome in which a 4 cm gallstone was not identified on abdominal plain films or CT. Although CT imaging has high sensitivity and specificity in diagnosis, iso-attenuating cholesterol stones may be obscured. Despite representing only 1-3% of cases of gallstone ileus, clinical suspicion for Bouveret syndrome must remain high in patient with evidence of GOO or bilioenteric fistula due to the high associated mortality, estimated between 12 - 30%.
Figure: A: CT abdomen/pelvis with evidence of gastric outlet obstruction but no visible gallstone; B: Upper GI series with ovoid-shaped filling defect visible C: Post-pyloric impacted gallstone visible during ERCP; D: Fragmented gallstone following electrohydraulic lithotripsy; E: Peri-pyloric tissue edema precluding complete stone extraction; F: Roth Net retriever used to extract stone
Aman Bali indicated no relevant financial relationships.
David DiSantis indicated no relevant financial relationships.
Frank Lukens indicated no relevant financial relationships.
Paul Kroner indicated no relevant financial relationships.
Aman S. Bali, MD1, David DiSantis, MD2, Frank J. Lukens, MD2, Paul T. Kroner, MD, MSc2. P0667 - The Case of the Invisible Stone: Bouveret Syndrome and the Importance of Clinical Judgment, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.