Bouveret's syndrome as an unusual cause of gastric outlet


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Bouveret's syndrome as an unusual cause of gastric outlet

  1. 1. Journal of Medical Case Reports BioMed CentralCase report Open AccessBouverets syndrome as an unusual cause of gastric outletobstruction: a case reportDeepak Joshi*1, Ali Vosough1, Tom M Raymond2, Chris Fox1 andArun Dhiman1Address: 1Department of Gastroenterology, William Harvey Hospital, Ashford, Kent, UK and 2Department of Surgery, William Harvey Hospital,Ashford, Kent, UKEmail: Deepak Joshi* -; Ali Vosough -; Tom M Raymond -;Chris Fox -; Arun Dhiman -* Corresponding authorPublished: 30 August 2007 Received: 16 January 2007 Accepted: 30 August 2007Journal of Medical Case Reports 2007, 1:73 doi:10.1186/1752-1947-1-73This article is available from:© 2007 Joshi et al; licensee BioMed Central Ltd.This is an Open Access article distributed under the terms of the Creative Commons Attribution License (,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract An 83 year old caucasian gentleman presented with vomiting and left sided abdominal pain. A subsequent upper GI endoscopy demonstrated a large smooth mass impacted within the duodenum. A cholecysto-duodenal fistula was discovered at laparotomy, with a large gallstone impacted in the duodenum. A diagnosis of Bouverets syndrome was made. The management of this rare cause of gastric outlet obstruction is discussed.Background dence of aerobilia or gallstones. A naso-gastric tube wasGallstones, in the majority of patients remain asympto- inserted. The patient subsequently underwent anmatic. The commonest clinical manifestation is biliary oesophago-gastro-duodenoscopy (OGD) to exclude pos-colic. Gallstone ileus occurs when a stone enters the intes- sible mechanical obstruction. At OGD, a mass was notedtinal tract via a cholecysto-enteric fistula. The authors beyond the pylorus (Figure 1). In the first part of the duo-present a case of Bouverets syndrome, a rare complication denum, the large smooth mass was seen occupying theof gallstone disease and rare cause of gastric outlet whole lumen with ulceration of the visible surroundingobstruction. mucosa (Figure 2). The mass was irretrievable endoscopi- cally.Case presentationAn 83 year old gentleman was admitted with a one week Computed tomography (CT) of the abdomen demon-history of vomiting after eating and left-sided upper quad- strated a large calcified mass in the first part of the duode-rant abdominal pain. There was no history of dysphagia num (Figure 3). The patient underwent an openor weights loss. The patient had suffered a similar episode laparotomy where a cholecysto-duodenal fistula wasthe year previously which had resolved spontaneously. found with a large gallstone impacted in the duodenum.Abdominal examination was unremarkable. No succes- No other synchronous gallstones were discovered. Thesion splash was evident. A full blood count, liver function gallstone was irretrievable and therefore a gastro-jejunos-tests and urea and electrolytes were normal. No free air tomy was performed. A diagnosis of Bouverets syndromeunder the right hemi-diaphragm was noted on a chest was made.radiograph. A plain abdominal film was negative for evi- Page 1 of 3 (page number not for citation purposes)
  2. 2. Journal of Medical Case Reports 2007, 1:73 thebulbView at 1 pylorus, demonstrating a mass in the duodenalView at the pylorus, demonstrating a mass in the duodenalbulb. Figure 3 Abdominal CT demonstrating a calcified mass in duodenum Abdominal CT demonstrating a calcified mass in duodenum.Post operatively the patient continued to produce largegastric aspirates via a naso-gastric tube. A repeat OGD spontaneously. Obstruction most commonly occurs indemonstrated that both afferent and efferent loops were the terminal ileum (90%) and less often in the duodenumpatent. The large gallstone was noted once again but this (3%) [2]. The differential diagnosis of gastric outlettime in the second part of the duodenum. The patient obstruction includes diverticulae, foreign bodies, fibroticreturned to theatre where this time the gallstone (Figure ulcers and neoplasia Gastric outlet obstruction secondary4) was successfully milked into the distal jejunum and to an impacted gallstone in the pyloric region or duodenalremoved via an enterotomy. The patient made an une- bulb is known as Bouverets syndrome. More common inventful recovery. elderly women, Bouverets syndrome presents with a non specific triad of epigastric pain, nausea and vomiting.Case discussion Abdominal and chest radiographs should be performedGallstone ileus is rare [1]. The majority of gallstones that looking for evidence of aerobilia, bowel obstruction andenter the GI tract via a cholecysto-enteric fistula are passed ectopic gallstones. Abdominal CT should also be per-Figure 2associated ulcerationA large smooth mass in the first part of the duodenum withA large smooth mass in the first part of the duodenum with Figure 4 Removed gallstoneassociated ulceration. Removed gallstone. Page 2 of 3 (page number not for citation purposes)
  3. 3. Journal of Medical Case Reports 2007, 1:73 Typical findings on OGD include a dilated stom-ach and a hard non-fleshy mass at the obstruction [3].Treatment options include endoscopic and surgical man-agement. Endoscopic removal should always beattempted first, but lithotripsy and stone extraction israrely successful [4]. Intracorporeal endoscopic electrohy-draulic lithotripsy has been used successfully in the treat-ment of Bouverets syndrome [5] Surgical options includeenterotomy and removal of the stones (enterolithotomy),enterolithotomy plus cholecystectomy and repair of thefistula, or gastric bypass surgery. The decision to use min-imal invasive surgery versus laparotomy should be madeon an individual patient basis and operator experience.Fistula repair is unnecessary due to spontaneous closureespecially if the cystic duct is patent and no residual stonesare present. Post operative mortality rates are high, andmay reflect the older subgroup of patients affected [6].ConclusionThe authors present a case of Bouverets syndrome in an83 year old gentleman. The diagnosis should be consid-ered in patients with symptoms of gastric outlet obstruc-tion with or without a history of gallstones or aerobiliaand typical endoscopic findings of a dilated stomach anda hard non-fleshy mass at the obstruction.Competing interestsThe author(s) declare that they have no competing inter-ests.Authors contributionsDJ, AV and TR were involved in writing of the case report.CF and AD were involved in the review and re-writing ofthe case report. All five authors were involved in thepatients care.AcknowledgementsWritten consent was obtained from the patient prior to submission.References1. Bhama JK, Ogren JW, Lee T, Fisher WE: Bouverets syndrome. Surgery 2002, 131:104-5.2. Clavien PA, Richon J, Burgan S, Rohner A: Gallstone ileus. Br J Surg 1990, 77:737-42.3. Capell MS, Davis M: Characterisation of Bouverets syndrome: Publish with Bio Med Central and every a comprehensive review of 128 cases. Am J Gastro 2006, scientist can read your work free of charge 101(9):2139-46.4. Marchall J, Hayton S: Bouverets syndrome. The American Journal "BioMed Central will be the most significant development for of Surgery 2004, 187:547-548. disseminating the results of biomedical researc h in our lifetime."5. Huebner ES, DuBois S, Lee SD, Saunders MD: Successful endo- Sir Paul Nurse, Cancer Research UK scopic treatment of Bouverets syndrome with Intracorpor- eal endoscopic electrohydraulic lithotripsy. Gastrointestinal Your research papers will be: endoscopy 2007, 66(1):183-184. available free of charge to the entire biomedical community6. Schweiger FJ, Shinder R: Duodenal obstruction by a gallstone (Bouverets syndrome) managed by endoscopic stone peer reviewed and published immediately upon acceptance extraction: a case report and review. Can J Gastroenterol 1997, cited in PubMed and archived on PubMed Central 11:493-6. yours — you keep the copyright Submit your manuscript here: BioMedcentral Page 3 of 3 (page number not for citation purposes)