Duodenal Obstruction by Gallstones (Bouveret’s Syndrome): a Review of the Literature

Introduction

Gallstone ileus accounts for 1-3 % of cases of obstructing ileus that require surgery, and is estimated to complicate 0.3 - 4.0 % of all cases of cholelithiasis [1] [2]. The level of obstruction is usually at the terminal ileum (60 - 70 %), proximal ileum (25 %), or distal ileum (10 %). Obstruction in the distal jejunum occurs in 9 % of cases, in the colon in 4 %, in the rectum in 2 %, and in the duodenum in only 1 - 3 % [2] [3]. As a general rule, the larger the stone, the more proximal the obstruction. Bouveret’s syndrome, first described in 1896 [4], is gastric outlet obstruction following the passage of a gallstone from the gallbladder to the duodenum via a cholecystoduodenal or choledochoduodenal fistula; it is therefore a rare condition. A case is shown in Figures [1] [2] [3] [4].

Figure 1 Computed-tomographic appearances in a patient with Bouveret’s syndrome. Note the pericholecystic inflammatory changes extending into the duodenum (a), gas in the gallbladder (b), and filling defects (gallstones) in the duodenum (c, d).

Figure 2 After initial improvement on intravenous antibiotic treatment, the patient became nonspecifically unwell and developed haematemesis and melaena. This prompted an urgent endoscopy, during which a large duodenal ulcer was seen. Subsequent endoscopy showed two deep duodenal ulcers and an unusual appearance resembling a fibrotic ulcer, which in retrospect probably represented a gallstone eroding through the duodenal wall.

Figure 3 The third endoscopy, showing gallstones within the lumen of the duodenum and obstruction at the level of the third part of the duodenum.

Figure 4 A water-soluble contrast meal in a patient with Bouveret’s syndrome. Contrast is seen in the gastric antrum and in the first and second parts of the duodenum and passing through a cholecystoduodenal fistula into the gallbladder. There are multiple filling defects (gallstones) in the gallbladder and duodenum, and complete duodenal obstruction. A combined cholecystectomy, gastrojejunostomy, and repair of the cholecystoduodenal fistula was carried out.

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