Bouveret's syndrome: A rare presentation of gallstone disease

fistula is a rare complication of gallstone disease and gallstone ileus is relatively a rare cause of intestinal obstruction. In most cases, the stone lodges in the distal ileum, colon or duodenum. The least common site of obstruction is the proximal duodenum or pylorus causing gastric outlet obstruction (Bouveret's syndrome). Presenting signs and symptoms of Bouveret's syndrome include nausea, vomiting, epigastric pain, and abdominal distension. Obstructive jaundice, gastrointestinal hemorrhage with or without hematemesis, pancreatitis, and duodenal perforation are less common. Abdominal radiography may show air in the biliary tree, mechanical bowel obstruction and radio-opaque gallstone suggesting the diagnosis. Abdominal ultrasound or computerized tomography is diagnostic in about 60% of cases. In most cases the treatment of Bouveret's syndrome is surgical. Surgical options include: (a) a single-staged enterolithotomy (or gastrotomy) with concomitant cholecystectomy and repair of the fistula or (b) an enterolithotomy alone with or without a second-stage cholecystectomy. Endoscopic extraction of the stone has been described in selected patients. Lithotripsy techniques have also been successfully used to fragment large stones. The authors present a case of Bouveret's syndrome as well as a brief literature review of this topic. DISCUSSIONfistula is a rare complication of gallstone disease (incidence, 0.3-0.5%) and gallstone ileus is relatively a rare cause of intestinal obstruction (3%). Most commonly the stone lodges in the distal ileum (90%), colon (3%-8%) or duodenum (3%). The least common site of obstruction is the proximal duodenum or pylorus causing gastric outlet obstruction, which is known as Bouveret's syndrome. The condition's presenting clinical signs and symptoms usually include nausea, vomiting, epigastric pain, and abdominal distension. Obstructive jaundice, gastrointestinal hemorrhage with or without hematemesis, pancreatitis, and