Teaching Case

A 79-year-old female patient presented to the emergency department with a 4-day history of nausea, vomiting, and epigastric pain.

Abdominal computed tomography with intravenous contrast material confirmed the presence of a gallstone in the proximal duodenum causing gastric outlet obstruction (stomach was partially decompressed by the presence of a nasogastric tube). This was associated with thickened duodenal wall, an adjacent contracted thick-walled gallbladder and cholecystoduodenal fistula (figure 2). In addition to this, air was present in the biliary tree as seen in figure 1, findings consistent with Bouveret´s syndrome.
An upper GI endoscopy was performed, showing a large gallstone in the first part of the duodenum (figure 3), multiple attempts to snare the stone were unsuccessful. Therefore surgical intervention was required for a definitive treatment, and the patient underwent open enterolithotomy (figure 4).

Bouveret´s syndrome is a rare cause of proximal gallstone ileus, consisting of a gastric outlet obstruction due to an impacted gallstone in the pylorus or duodenal bulb by way of a cholecystoenteric fistula [1]. Long term and silent cases of cholecystitis can cause secondary inflammation of the adjacent duodenal wall, and sometimes gallstones may fistulate directly into the duodenum from the gallbladder, resulting in a cholecystoenteric fistula [2].
It is most commonly seen in elderly women and manifests as nonspecific symptoms including nausea, vomiting, and epigastric pain.
Identification of the Rigler triad (pneumobilia, ectopic gallstone, and obstruction) at CT is more common. CT scan can be useful to evaluate features such as pneumobilia, dilated stomach, ectopic gallstone, cholecystoduodenal fistula, and thickened duodenal wall [3].
These patients are often poor surgical candidates due to concomitant illnesses and their advanced age, so endoscopy treatment is preferred as initial therapeutic option [3, 4].