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Bouveret's syndrome: a rare complication of gallstone disease

A 63-year-old female patient presented with epigastric pain and vomiting. Laboratory tests showed high levels of pancreatic enzymes, reaching six times the upper normal value and normal liver function tests. An abdominal ultrasonography was performed, finding gallbladder stone filled. In the suspicion of acute pancreatitis, she was admitted and treated with bowel rest and intravenous hydration. CT scan showed no sign of pancreatitis while, surprisingly, a 3.2-cm gallstone with characteristic eggshell-like calcification was seen in duodenum (Fig. 1). An upper endoscopy revealed an extensive ulceration of the duodenal bulb (Fig. 2) and confirmed a large gallstone impacted in the distal duodenum (Fig. 3). Multiple endoscopic attempts to extract the stone were unsuccessful. Patient underwent laparotomy and the stone was removed by duodenotomy without cholecistectomy and fisula repair. Bouveret’s syndrome is a rare entity defined as gastric outlet obstruction caused by an impacted gallstone passing in the duodenum or pylorus through a bilioduodenal or biliogastric fistula. It occurs most commonly in elderly women. The clinical features are not pathognomonic and are characterized by nausea, vomiting and abdominal pain. The laboratory findings are usually nonspecific. Endoscopy is the mainstay of diagnosis and abdominal CT is useful when the diagnosis is not straightforward. In most cases the treatment is surgical, but it has also been successfully treated by endoscopy. The mortality rate can reach 25% (1, 2). Although the condition is rare, Bouveret’s syndrome should be kept in mind as a possible complication of gallstone disease, especially in elderly women.