Gastric outlet obstruction - looking for a syndrome: Bouveret or Mirizzi?

Introduction and importanceGastric outlet obstruction can result from any pathological process that causes intrinsic blockage or extrinsic pressure on the distal stomach and duodenum. Gallstone related gastric outlet obstruction is a well-known entity classically due to a cholecystoenteric fistula formation.Case presentationWe present here a case of a 36-year-old man who presented with right upper quadrant abdominal pain associated with marked nausea and vomiting. Abdominal CT scan done in the emergency department revealed a large impacted infundibular gallstone with signs of acute cholecystitis, associated with prominent gastric distention. Gastric outlet obstruction was due to stenosis at the duodenal level from external compression by the large impacted stone with no evidence of fistula. Laparoscopic cholecystectomy was performed with total resolution of symptoms.Clinical discussionGastric outlet obstruction can be secondary to many etiologies, and notably gallstone disease. Classically this is due to formation of a cholecystoenteric fistula and intrinsic obstruction by the migrated stone. Our case is unique in that a large impacted infundibular gallstone caused gastric outlet obstruction with absence of any fistula or gallstone migration.ConclusionGastric outlet obstruction due to external compression by a non-migrated gallstone is a rare undescribed entity. Surgical treatment should not be delayed to prevent complications and fistula formation.     

Gallstone perforation and obstruction of the duodenal bulb.

A 69-year-old woman had a large gallstone eroded through the wall of the gallbladder and into the duodenum. The gallstone became fixed within the cholecystoduodenal fistula and produced a duodenal obstruction. At the time of the diagnosis of this problem, the patient had had a three-week period of epigastric pain and prolonged vomiting. She was treated by removal of the stone and cholecystectomy. The duodenal fistula was closed in two layers, and a gastrojejunostomy and a truncal vagotomy were carried out to protect the duodenal suture line. A leak from the duodenal closure developed on the fourth day, but this subsided spontaneously after 15 days with the use of sump drainage. Six months later, the patient is doing well and has a normal duodenum and gastrojejunostomy as shown by upper gastrointestinal barium study.     

The Relationship of Mirizzi Syndrome and Cholecystoenteric Fistula: Validation of a Modified Classification

BACKGROUND: Mirizzi syndrome and cholecystoenteric fistula with or without gallstone ileus are late complications of gallstone disease. We previously suggested that the natural history of Mirizzi syndrome may not end with just a cholecystobiliary fistula and that the continuous inflammation in the triangle of Calot area may result in a complex fistula involving the biliary tract and the adjacent viscera. The purpose of this study was to establish the relationship of Mirizzi syndrome with cholecystoenteric fistulas. METHODS: We retrospectively reviewed the records of all patients older than aged 18 years submitted to emergency or elective cholecystectomy from 1995 to 2006. Of 5,673 cholecystectomies performed during that period, we found 327 (5.7%) patients with Mirizzi syndrome and 105 (1.8%) patients with cholecystoenteric fistula. Ninety-four (89.5%) patients with cholecystoenteric fistula also had an associated Mirizzi syndrome. RESULTS: Cholecystoenteric fistula was associated with Mirizzi syndrome (p < 0.0001), increased age was associated with Mirizzi syndrome and cholecystoenteric fistula (p < 0.0001), and female gender was associated with Mirizzi syndrome (p < 0.0001). CONCLUSION: When during surgery for gallstone disease a cholecystoenteric fistula is encountered, the possibility of an associated Mirizzi syndrome must be considered. The findings of this study confirm the association of Mirizzi syndrome with cholecystoenteric fistula.     

Duodenal obstruction by gallstone: case report of Bouveret's syndrome.

Bouveret's syndrome involves gastric outlet obstruction by gallstone. Herein we describe an unusual case of duodenal bulb obstruction by gallstone. An 80-year-old woman was hospitalized with a fifteen-day history of vomiting. Computed tomography (CT) showed pneumobilia and a round calcified mass in the second portion of the duodenum. Upper gastrointestinal tract series demonstrated the same sized oval radiolucency between the bulbus and the second portion of the duodenum. Endoscopic examination revealed a round black mass in the second portion of the duodenum, totally occupying the lumen. Endoscopic removal and destruction of the gallstone was attempted using a dye-laser, but the stone was too hard to crush. Eventually surgical enterolithotomy was successfully performed without cholecystectomy or closure of the fistula. Improved preoperative systemic management and prompt examination allowed earlier surgical intervention and reduced the morbidity. Surgical approach whether fistula closure should be performed remains controversial.     

Recurrence of gallstone ileus with Crohn's disease

Gallstone ileus is an uncommon form of bowel obstruction. It can occur whenever a stone passes through the common bile duct or a cholecystoenteric fistula. When a stone is in the intestinal track it can either traverse the entire colon to be voided spontaneously or obstruct the small or more rarely the large intestine. We report a case of recurrence of gallstone ileus in a young patient with Crohn's disease. Clinical findings, diagnosis and treatment are presented.     

胆囊十二指肠瘘伴胆石性肠梗阻1例分析并文献复习

目的:探讨胆囊十二指肠瘘合并胆石性肠梗阻的术前评估、诊断和手术方式。方法:回顾性分析1例胆囊十二指肠瘘合并胆石性肠梗阻术前及术中的临床资料,并复习相关文献。结果:患者术前CT检查考虑胆囊结石与胆石性肠梗阻。术中探查见回盲部40cm处结石嵌顿,随后成功行肠切开取石、十二指肠瘘口修补、胆囊切除。术后痊愈出院,随访至目前未见相关并发症。结论:胆囊十二指肠瘘合并胆石性肠梗阻临床罕见,早期的明确诊断及精确的评估是关键,应根据患者具体情况选择合适的手术方式。     

Bouveret's syndrome: successful endoscopic treatment of gastric outlet obstruction caused by an impacted gallstone

Bouveret's syndrome is defined as gastric outlet obstruction caused by duodenal impaction of a large gallstone which passes into the duodenal bulb through a cholecystogastric or cholecystoduodenal fistula. This is a report of a 62 years old female who presented with complaint of persistent vomiting and upper abdominal pain for the last 5 days. Ultrasound abdomen was suggestive of pneumobilia. CT scan of upper abdomen showed cholecystoduodenal fistula and complete obstruction of third part of duodenum by a large stone, which was reported as Bouveret's syndrome. She underwent emergency gastroscopy. The stone was retrieved by Dormia basket, crushed with lithotripter and extracted endoscopically.Complete intestinal obstruction was relieved endoscopically.     

A case of gallstone ileus displaying spontaneous closure of cholecystoduodenal fistula after enterolithotomy

INTRODUCTIONGallstone ileus, a rare complication of cholelithiasis and cholecystitis, is a relatively rare cause of alimentary tract obstruction. It is usually associated with a cholecystoenteric fistula through which a gallstone has passed into the gastrointestinal tract. Cholecystoenteric fistula uncommonly closes spontaneously, the period between formation and closure having rarely been reported. In addition, endoscopic detection of cholecystoenteric fistulous closure has seldom been reported.PRESENTATION OF CASEWe report a 51-year-old Japanese man with gallstone ileus in whom spontaneous closure of a cholecystoduodenal fistula was observed by endoscopy 2 weeks after laparoscopy-assisted enterolithotomy.DISCUSSIONLaparoscopy-assisted enterolithotomy for gallstone ileus allows direct diagnosis of gallstone ileus and assessment of the status of adhesions affecting the biliary tract.CONCLUSIONEndoscopic confirmation of fistulous closure after laparoscopy-assisted enterolithotomy is a minimally invasive approach that may avert the need for biliary surgery.     

Bouveret Syndrome

Gastric outlet obstruction secondary to an impacted duodenal gallstone, or Bouveret syndrome, is a rare variant of gallstone ileus. It is most common in elderly women and frequently requires endoscopic or surgical management. We present the case of an 80-year-old woman with multiple medical comorbidities who presented to our service with 2 weeks of abdominal pain and nausea. MRI revealed a 4.4-cm gallstone impacted in the duodenum with associated cholecystoduodenal fistula. She required operative exploration to remove the impacted stone and had an unremarkable post-operative course. This case demonstrates the presentation and workup of this rare disorder and the various options for treatment, which can sometimes be difficult given the typical age and associated comorbidities of the patient.     

Gallstone ileus in the absence of the gallbladder: case report and review of the literature

Although small-bowel obstruction due to gallstone ileus is uncommon, it assumes increasing importance with advancing age. The obstructing gallstone enters the bowel through an internal fistula between gallbladder and duodenum. The authors describe the case of a patient who had undergone cholecystectomy and in whom gallstone ileus occurred secondary to a stone that entered the bowel through a choledochoduodenal fistula. Treatment was traditional with removal of the obstructing stone, but the fistula was left undisturbed. The authors believe that further biliary tract symptoms are unlikely. The patient was well 8 weeks after operation and roentgenograms indicated that the internal biliary fistula was patent.     

Gallstone ileus in patient with Crohn’s disease

Gallstone ileus is an uncommon form of bowel obstruction, related in the majority of cases to a cholecystoenteric fistula. In patients with Crohn’s disease the stone can obstruct the diseased bowel. We report a case of gallstone ileus in a patient with Crohn’s disease. An explorative laparoscopy and a minimally-invasive laparotomy were achieved to resolve the obstruction. Cholecystectomy and closure of the cholecystoduodenal fistula were not performed. The association of gallstone ileus and Crohn’s disease is very rare; only few cases are reported in the literature. Laparoscopic approach could identify the extension of the disease and the site of impaction, allowing the differential diagnosis in particular in patients with Crohn’s disease. In the cases described, cholecystectomy and the closure of the fistula were not performed considering the absence of any residual stone in the gallbladder and the associated risk of treating the cholecysto-duodenal fistula in an emergency settings.     

Gallstone ileus as a complication of cholecystolithiasis

Biliary fistula and gallston ileus are rarely found. The diagnosis is difficult. Gallstone ileus requires urgent and appropriate surgical therapy. Enterolitotomy remains the gold standard of operative treatment for gallstone ileus, but additional procedures of one-stage cholecystectomy and repair of fistula are necessary. Some researchers advise first to resolve the gallstone ileus and then to perform the elective operation for gallstone disease in more ideal circumstances. Our case had clinical evidence of ileus, which was confirmed by radiological exam. Ultrasonographic examination performed before operation did not confirm the presence of gallbladder; it did not detect a large stone located in the intestine. The patient, a 75-year-old woman, was operated on. During the procedure it was shown that the second part of the duodenum was involved in a scar and displaced to the hepatic hilus. There was no gallbladder; it was probably destroyed by a long-lasting vesicoduodenal fistula. Cholangiography also did not detect the gallbladder. Biliary passage through the common bile duct was sufficient. The hole in the duodenum wall was sutured, and Kehr drain was inserted into the common bile duct. The gallstone was removed by incision of the intestine down to the obstruction. The postoperative period was complicated by a small suppuration of the laparotomy wound. Vesicoduodenal fistula present for a long time can lead to atrophy of the gallbladder. The one-stage procedure seems to be appropriate if biliary fistula and gallstone ileus are found.     

Laparoscopic management of gallstone ileus.

Gallstone ileus is an uncommon entity that was first described by Bartholin in 1654. Despite advances in perioperative care, morbidity and mortality remain high in patients with gallstone ileus because: 1) they are geriatric patients; 2) they often have multiple comorbidities; 3) presentation to the hospital is delayed; 4) many are volume depleted with electrolyte abnormalities; and 5) the diagnosis of gallstone ileus is difficult to make. Traditional management has entailed open laparotomy with relief of intestinal obstruction by enterotomy and stone extraction. Cholecystectomy and takedown of the cholecystoenteric fistula can be performed. We propose an alternative method of management in an attempt to limit operative trauma and improve morbidity and mortality. We review the literature and describe two patients with gallstone ileus who were managed laparoscopically. One patient underwent laparoscopic assisted enterolithotomy, and the other patient underwent diagnostic laparoscopy with disimpaction of the gallstone into the large bowel. They were discharged after their ileus had resolved on the fourth and sixth postoperative day, respectively. Laparoscopy is a powerful diagnostic and therapeutic tool that can be effectively used to treat gallstone ileus.     

Laparoscopic treatment of a gastric outlet obstruction caused by a gallstone (Bouveret's syndrome)

Duodenal impaction of a gallstone after its migration through a cholecystoduodenal fistula is an uncommon cause of gallstone ileus described as Bouveret's syndrome. Surgical treatment is recommended, but the morbidity and mortality rates are nearly 60% and 30%, respectively. To reduce these rates using improved endoluminal surgery, a laparoscopically assisted intraluminal gastric surgery could be considered. A 74 year-old woman was admitted with typical Bouveret's syndrome. An intraluminal gastric laparoscopy was performed. The large stone impacted in the first duodenum was removed through the pylorus and pulled into the stomach. After its mechanical fragmentation, the stone was extracted with a sterile retriever bag through the main trocar. In the case of Bouveret's syndrome, treatment of the duodenal obstruction is mandatory. Surgical treatment of the cholecystoduodenal fistula still is controversial. We never perform a one-stage procedure, and we reserve a biliary operation for the patient who remains symptomatic. In this way, laparoscopically assisted intraluminal gastric surgery with transpyloric extraction of the stone can be a safe and interesting approach for this type of pathology.     

A rare cause of upper gastrointestinal haemorrhage: Ruptured cystic artery pseudoaneurysm with concurrent cholecystojejunal fistula

INTRODUCTION Cystic artery pseudoaneurysms and cholecystoenteric fistulae represent two rare complications of gallstone disease.PRESENTATION OF CASE An 86 year old male presented to the emergency department with obstructive jaundice, RUQ pain and subsequent upper gastrointestinal bleeding. Upper GI endoscopy revealed bleeding from the medial wall of the second part of the duodenum and a contrast-enhanced computed tomography scan revealed a cystic artery pseudoaneurysm, concurrent cholecystojejunal fistula and gallstone ileus. This patient was successfully managed surgically with open subtotal cholecystectomy, pseudoaneurysm resection and fistula repair.DISCUSSION To date there are very few cases describing haemobilia resulting from a bleeding cystic artery pseudoaneurysm. This report is the first to describe upper gastrointestinal bleeding as a consequence of two synchronous rare pathologies: a ruptured cystic artery pseudoaneurysm causing haemobilia and bleeding through a concurrent cholecystojejunal fistula.CONCLUSION Through this case, we stress the importance of accurate and early diagnosis through ultra- sonography, endoscopy, and contrast-enhanced CT imaging and emphasise that haemobilia should be included in the differential diagnosis of anyone presenting with upper gastrointestinal bleeding. We have demonstrated the success of surgical management alone in the treatment of such a case, but accept that consideration of combined therapeutic approach with angiography be given in the first instance, when available and clinically indicated.     

Bouveret syndrome and gallstone ileus

Intestinal obstruction from gallstones is a rare complication of gallstone disease. These ectopic gallstones can cause obstruction anywhere from the duodenum to the colon and are accompanied by a cholecystoduodenal/enteric/colic fistula. We report an 81-year-old male who presented with gallstone obstruction of the duodenum who underwent attempted endoscopic fragmentation and extraction that eventually led to small bowel obstruction from an impacted fragment of the stone. He underwent successful enterolithotomy and has been asymptomatic from the cholecystoduodenal fistula. Surgery is the gold standard for the treatment of this condition but the extent of the operation remains a matter of debate.     

Bouveret's syndrome presenting as upper gastrointestinal hemorrhage without hematemesis

A 74-year-old woman with a recent diagnosis of peptic ulcer disease diagnosed by endoscopy after presentation with an episode of upper gastrointestinal bleeding returned 6 1/2 weeks later with a 5-day history of nausea and vomiting without associated symptoms. An ultrasound was nondiagnostic except for a large gallstone and a poorly visualized gallbladder. Repeat endoscopy revealed a hard mass that was presumed to have formed secondarily to an ulcer-induced stricture, and a 6-cm filling defect just proximal to the duodenal bulb was seen on a preoperative upper gastrointestinal series. At laparotomy the mass was actually a large gallstone and two smaller stones, which had eroded into and become impacted in the duodenal bulb creating a gastric outlet obstruction. The stones were extracted via a duodenotomy, and the remaining portion of the gallbladder was removed with repair of the cholecystoduodenal fistula. The patient was discharged home after an uncomplicated postoperative course. Gastric outlet obstruction by a duodenal gallstone is a condition known as Bouveret's syndrome, which is a rare complication of gallstone disease. Upper gastrointestinal hemorrhage is an especially rare form of presentation.     

Subtotal colectomy in the course of gallstone-ileus surgery

A big gallstone penetrating through a bilio-digestive fistula into the bowel can make a complete obstruction of it in the majority of the cases requiring an urgent operation. It is a rare situation that a fistula like this leads into the colon and the stone makes a large bowel obstruction. A 72-year-old male patient was admitted to our department with the symptoms of colon obstruction. After the examinations he underwent an explorative laparotomy. During the course of the operation an obstruction was found in the proximal third of the descending colon. A subtotal colectomy was carried out. At the opening of the resected colon a big gallstone was found as the cause of the obstruction, which simulated a tumorous obstruction. We present through this case the possibilities and results of the diagnosis and treatment of gallstone ileus. We conclude that in the prevention of gallstone ileus, the early operative treatment of detected gallstone is essential.     

Successful treatment of duodenal bulb obstruction caused by a gallstone (Bouveret's syndrome) after endoscopic mechanical lithotripsy

Because of acute symptoms in the upper abdomen, upper gastrointestinal endoscopy was performed in a 68-year-old man. A large perforated gallstone was embedded in the duodenum, causing complete obstruction of the duodenal bulb. The stone was crushed successfully by endoscopic mechanical lithotripsy. The patient was referred for surgery, and was discharged after a successful and uneventful cholecystectomy.     

Gallstone ileus as a complication of acute cholecystitis. Laparoscopic diagnosis and treatment

Gallstone ileus accounts for 1-4% of all cases of intestinal obstruction, with its incidence rising with age of patients. There is often a long delay between onset of symptoms (usually abdominal pain, vomiting, and bowel distension) and proper treatment, with a simple enterolithotomy as the one of choice. We report a case of an atypical gallstone ileus presented as a complication of acute cholecystitis, treated with a laparoscopic guided enterolithotomy. A 67-year-old woman on the 5th p.o. day after a laparoscopic procedure for an empyematous cholecystitis (no sign of fistula or duodenal perforation and a "negative" intraoperative cholangiography) presented continuous vomiting as the only symptoms of a subileus (radiographic diagnostic images negative for intestinal obstruction or intraluminal gallstone or duodenal fistula). A laparoscopic diagnostic approach revealed a gallstone in the distal jejunum. Through a 5 cm midline incision the intestine, including the gallstone, was brought out extracorporally and the stone was removed by a simple enterolithotomy. The postoperative course was uneventful and the patient had no complaint at a 1-year follow-up. We consider the laparoscopic approach, in patients with "abdominal emergencies," feasible and safe in experienced hands. It provides diagnostic accuracy as well as therapeutic capabilities, as in the case of gallstone ileus we have reported.