Bouveret syndrome
✅ Bouveret Syndrome – Quick Overview
🔎 Definition:
Bouveret syndrome is a rare form of gallstone ileus, where a large gallstone causes gastric outlet obstruction by impacting in the duodenum or pylorus. It occurs after a cholecystoenteric fistula forms, typically between the gallbladder and duodenum.
⚡ Pathophysiology
- Chronic cholelithiasis (gallstones) →
- Repeated inflammation of the gallbladder →
- Formation of a fistula (usually cholecystoduodenal) →
- Large gallstone passes from gallbladder into duodenum →
- Gallstone lodges at the pylorus or duodenum →
- Leads to gastric outlet obstruction →
- Causes symptoms of vomiting, epigastric pain, and early satiety.
⚠️ Key Clinical Features
- Age group: Elderly patients, often women > 70 years
- Symptoms:
- Persistent vomiting (non-bilious or bilious depending on obstruction)
- Epigastric pain
- Early satiety
- Abdominal distension
- Weight loss
- Possible history of cholelithiasis
🔍 Diagnosis
- Imaging studies:
- Abdominal X-ray: May show pneumobilia (air in biliary tree), ectopic gallstone, and signs of obstruction
- CT scan (preferred): Best for detecting cholecystoenteric fistula and obstructing gallstone
- Upper GI endoscopy: May directly visualize impacted gallstone in duodenum/pylorus
🚑 Treatment
- Endoscopic removal – first attempt, especially in high-risk surgical patients
→ Methods: Mechanical lithotripsy, laser lithotripsy, or extraction with basket - Surgical approach (if endoscopy fails):
- Enterolithotomy (stone removal through duodenotomy or gastrotomy)
- Cholecystectomy and fistula repair (optional depending on patient stability)
Which is currently the first line of treatment of Bouveret syndrome?
A. Open surgery
B. Laparoscopic Surgery
C. Endoscopic intervention
D. Surgery if conservative management fails
Bouveret syndrome is the most infrequent variant of gallstone ileus.
Gastric outlet obstruction.
Bouveret syndrome is caused by a large stone passing through a bilioduodenal fistula causing gastric outlet obstruction.
Mortality
Bouveret syndrome has a high mortality, estimated at 12 to 30%, because an elderly age group is usually afflicted, delay of diagnosis owing to its non-specific presentation and complexity of the disease.
Entry point of gall stone
Entry point is typically a fistula between the gallbladder and a portion of the stomach or intestine.
Rigler’s triad -Imaging
Pneumobilia, bowel obstruction, and an aberrant gallstone referred to as Rigler’s triad.
Rigler’s triad is highly suggestive of Bouveret syndrome.
Rigler’s triad – only found in 40% to 50% of cases.
Spontaneous resolution of Bouveret syndrome after conservative treatment is rare and a dislodged stone can cause distal obstruction.
First line of treatment
Endoscopic intervention is currently the first line of treatment of Bouveret syndrome.
[Cholelithiasis] ➔ [Cholecystoenteric Fistula] ➔ [Gallstone enters duodenum/pylorus] ➔ [Obstruction] ➔ [Vomiting, Epigastric pain] Key Triad: 1. Gastric outlet obstruction 2. Pneumobilia 3. Ectopic gallstone
