A0725 - A Rare Case of Bouveret's Syndrome

Joseph A. Salhab, DO¹, Arsalan Ahmed, ^2
1AdventHealth, Davenport, FL; ²AdventHealth, Windermere, FL

Introduction: Bouveret syndrome is an extremely rare complication of gallstone disease that results in a gastric outlet obstruction caused by an impacted gallstone at the pylorus or proximal duodenum. It typically occurs after the formation of a fistula between the gallbladder and the duodenum or stomach in the setting of chronic gallbladder inflammation. If not detected early, it can result in a gallstone ileus and has a high rate of morbidity and mortality. Here we present the case of a 81 year old male who presented to our institution with inability to tolerate PO intake for 1 week with CT findings suggestive of a gastric outlet obstruction of unknown etiology.

Case Description/Methods: The patient is an 81 year old male with a PMHx of BPH, Vertigo, and Glaucoma who presented to our institution with the CC of generalized abdominal pain and inability to tolerate PO intake for 1 week. CT of the AP on admission demonstrated abnormal thickening and inflammatory changes at the pyloroduodenal junction with a high attenuation intraluminal density within this region, along with severe distention of the stomach. There was also extensive pneumobilia present. Pre-operative EGD demonstrated a distended stomach, residual food within the gastric lumen, and impacted density at the pylorus that appeared to be a gallstone. Endoscopic retrieval could not be performed as the gallstone appeared to be located within the duodenum. The patient was referred to the surgical service and he subsequently underwent laparotomy which demonstrated findings of acute cholecystitis, a cholecysto-duodenal fistula, and a large impacted gallstone within the proximal duodenum that was 7 x 5 x 4 cm in size. The surgical service performed a cholecystectomy, duodenotomy with removal of the impacted gallstone, repair of the cholecysto-duodenal fistula, and placement of a tube duodeno-jejunostomy. The patient's hospital course was complicated by fluid collection that required CT-guided percutaneous drainage by the IR service.

Discussion: Bouveret syndrome is a rare complication of chronic gallbladder disease and represents approximately 1% to 3% of gallstone obstructions found within the GI tract. Diagnosis relies on cross sectional imaging and a diagnostic (and attempted therapeutic) upper endoscopy. While first line therapy is typically attempted with an upper endoscopy with stone extraction, it is often accompanied by poor success rates compared to surgical intervention. This syndrome has a high morbidity and mortality if not recognized early.


Disclosures:


Joseph A. Salhab, DO¹, Arsalan Ahmed, ². A0725 - A Rare Case of Bouveret's Syndrome, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.