Updates Surg (2013) 65:63–65
DOI 10.1007/s13304-011-0131-2
CASE REPORT
Bouveret’s syndrome: endoscopic or surgical treatment
A. Hussain • S. Obaid • S. El-Hasani
Received: 23 March 2011 / Accepted: 28 December 2011 / Published online: 12 January 2012
Ó Springer-Verlag 2012
Introduction
Bouveret’s syndrome (BS) is a gastric outlet obstruction
caused by duodenal impaction of a large gallstone migrated
through a cholecystoduodenal fistula and was described by
León Bouveret [1]. Up to January 2011, there were 184
relevant publications in the Medline with 151 case reports
of BS. Many cases are reported however the outcomes are
not always successful and, therefore, a refinement of
management plan for this specific group of elderly and frail
patients is mandatory.
Duodenal obstruction may be caused by different lesions
(see Table 1). The commonest cause of duodenal obstruc-
tions in the adults was benign diseases, however, the trend is
changing and benign diseases are reported in minority of
patients with gastric outlet obstruction while malignancy is
the predominant cause in the remaining patients [2].
Case report
A 78-year-old female patient presented with mild epigas-
tric pain, nausea and persistent vomiting for 3 weeks.
There was no past history of significant medical problems.
On examination, the pulse rate was 105/min, blood pres-
sure 100/55 mmgh, temperature 36.7 co; mild dehydration,
distended soft abdomen with mild tenderness and fullness
A. Hussain, H. Mahmood, S. Obaid and S. El-Hasani contributed
equally to this work.
A. Hussain (&)
S. Obaid
S. El-Hasani
General Surgery Department, Princess Royal University
Hospital, Farnborough Common Orpington, Greater London
BR6 8ND, UK
e-mail: azahrahussain@yahoo.com
in the epigastric area; WBC 7.3 9 109/L, C reactive pro-
tein (CRP) 36 mg/L, urea 13.3 mmol/L and normal liver
function were observed. Intravenous fluid, nasogastric tube
and urinary catheters were performed. The chest and
abdominal X-rays showed dilated stomach with no obvious
cause. Naso-gastric tube drained 3 L of bile stained fluid.
An urgent CT scan showed duodenal obstruction sec-
ondary to a gallstone (4.3 cm in diameter) with gas in the
biliary radicals, collapsed gall bladder and distended
stomach and dilated proximal duodenum. Gastroscopy was
done but failed to retrieve the stone and an urgent midline
laparotomy was performed. The right colon was reflected
towards midline and the duodenum was kocherised. The
stone was removed from the distal part of the duodenum.
The duodenotomy was closed using interrupted polydiox-
anone sutures. The patient developed uneventuval recovery
and was discharged with stable condition on the 10th
postoperative day. Postoperative follow-up at 2 and 8 months
was unremarkable.
Discussion
Bouveret’s syndrome (BS) is a rare condition and the total
number of reported cases is 151 [3–6]. The classical case is
an elderly female patient known to have gallstones. The
stone is usually eroding through duodenal wall forming
cholecystoduodenal fistula. The fate of the stone is
depending on its size and presence or absence of bowel
narrowing (due to whatever cause). The stone may pass
spontaneously; lodge in the terminal ileum or the duode-
num, or before benign or malignant strictures. The com-
monest presentation of BS is nausea and vomiting (87%);
however, abdominal pain, bleeding, pancreatitis, perfora-
tion and weight loss are the other possible presentations
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Table 1 Rare causes of
Congenital
duodenal obstruction
Trauma
Infection, infestation
Inflammatory
Tumours
Foreign body
Anatomical
Post-surgical
[7]. The signs are ranging from mild to severe depending
on the degree and duration of obstruction. Epigastric full-
ness and tenderness, dehydration, tachycardia and hypo-
tension are the commonest signs.
The workup investigations are full blood count, bio-
chemistry, liver function, coagulation, amylase, and arterial
blood gas analysis. Chest and abdominal X-rays are the
initial radiological tests. Metabolic alkalosis may be a
finding.
Gastroscopy, upper GIT series, USS, CT and MRI are
the most helpful tests to confirm the cause. CT scan is
providing the diagnosis in the majority of cases and it is
indicated in emergency situations to assess an elderly
patients presenting with obstruction. Although CT finding
of gas in the biliary tree, collapsed gall bladder and gall-
stone in the duodenum is pathognomonic of BS (see
Fig. 1), gastroscopy is needed in most cases and is con-
sidered as the most specific diagnostic test and some times
it can be therapeutic. Endoscopic retrieval of the stones is
Fig. 1 a CT showed gas in the
biliary tree, dilated stomach and
duodenum, b endoscopic view
of the stone lodged in the third
part of duodenum. c Stone after
extraction (4.3 cm in diameter)
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Updates Surg (2013) 65:63–65
Anular pancreas, duodenal atresia, superior mesenteric syndrome,
preduodenal portal vein, choledochal cyst, situs inversus totalis,
Curry-Jones syndrome
Duodenal haematoma, retroperitoneal trauma
Duodenal diverticulitis, TB, parasite (Strongyloides stercoralis)
Pancreatitis phlegmon, Crohn’s disease, retroperitoneal fibrosis
Duodenal carcinoma, lymphoma, polyp, gastrinoma, lipoma
Any swallowed foreign bodies, stent, migrated gastric balloon,
bezoar/phytobezoar
Duodenal diverticulum, duodenal web
Post-aortic aneurysm repair
reported in the literature and it is the best mode of man-
agement as it provides the benefits of minimal access
approach [8].
However, the success depends on the presence of ade-
quate endoscopic skills and if the stone is small. Some of
the gallstones can be crushed and removed in pieces using
lithotripters. Few sessions of endoscopic management may
be needed in certain patients. However, in the majority of
reported cases, surgical exploration is used. This is because
of the size of the stone, lack of the endoscopic skills and
instrumentation, emergency setting and exploratory lapa-
rotomy without preoperative diagnosis and also because of
failed endoscopy [7, 9]. In challenging clinical scenario
with large stone more than 3 cm, exploratory laparotomy
and removal of the stone through enterotomy may be the
only way to cure the obstruction as in our case [10].
However, the option of one stage surgery of enterolithot-
omy, cholecystectomy and closure of the fistula is a major
undertaking in an emergency situation involving frail
Updates Surg (2013) 65:63–65
patient with comorbidities. This option may be reserved for
young fit patient with long life expectancy. The postoper-
ative complications of cholecystitis or cholangitis follow-
ing enterolithotomy alone are relatively low and we did
not report these in four similar patients treated by sole
enterolithotomy at our institution. The two-stage proce-
dure of enterolithotomy followed by cholecystectomy and
closure of the fistula may be considered in patients who have
biliary colic, recurrence of cholecystitis due to residual stone
or cholangitis. Similar to enterotomy for obstruction because
of bezoars, the surgeon should check the proximal small
bowel for second gallstone when operating on small bowel
obstruction due to gall stone ileus.
Conflict of interest All authors declare there is no conflict of
interest of any kind in relation to this article.
References
1. Crespo Pérez L, AngueiraLapeña T, Defarges Pons V,
ForunyOlcina JR, Cano Ruiz A, Benita León V, GónzalezMartı́n
JA, Boixeda de Miquel D, MilicuaSalamero JM (2008) A rare
cause of gastric outlet obstruction: Bouveret’s syndrome. Gas-
troenterol Hepatol 31:646–651
65
2. Kochhar R, Kochhar S (2010) Endoscopic balloon dilatation for
benign gastric outlet obstruction in adults. World J Gastrointest
Endosc 16:29–35
3. Gencosmanoglu R, Inceoglu R, Baysal C, Akansel S, Tozun N
(2003) Bouveret’s syndrome complicated by a distal gallstone
ileus. World J Gastroenterol 9:2873–2875
4. Zippi M, Di Stefano P, Manetti G, Febbraro I, Traversa G,
Mazzone AM, De Felici I, Mattei E, Occhigrossi G (2009)
Bouveret’s syndrome: description of a case. CinTer 160(9):367
5. Mittal S, Sutcliffe RP, Rohatgi A, Atkinson SW (2009) A pos-
sible variant of Bouveret’s syndrome presenting as a duodenal
stump obstruction by a gallstone after Roux-en-Y gastrectomy: a
case report. J Med Case Reports 28:7301
6. Báez-Garcı́a J, Martı́nez-Hernández-Magro P, Iriarte-Gállego G
(2009) Bouveret’s syndrome: a case report. Rev Gastroenterol
Mex 74:118–121
7. Cappell MS, Davis M (2006) Characterization of Bouveret’s
syndrome: a comprehensive review of 128 cases. Am J Gastro-
enterol 101:2139–2146
8. Rehman A, Hasan Z, Saeed A, Jamil K, Azeem Q, Zaidi A,
Abduallah K, Rustam T (2008) Bouveret’s syndrome. J Coll
Physicians Surg Pak 18:435–437
9. Rogart JN, Perkal M, Nagar A (2008) Successful multimodality
endoscopic treatment of gastric outlet obstruction caused by an
impacted gallstone (Bouveret’s Syndrome). Diagn Ther Endosc
47:1512
10. Fancellu A, Niolu P, Scanu AM, Feo CF, Ginesu GC, Barmina
ML (2010) A rare variant of gallstone ileus: Bouveret’s syn-
drome. J Gastrointest Surg 14:753–755
123