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.     

Gastric outlet obstruction by a gallstone (Bouveret's syndrome)

Gastric outlet obstruction caused by a gallstone in the duodenum or pylorus(Bouveret's syndrome) is a very rare complication of gallstone disease. Presenting symptoms include epigastric pain, nausea, and vomiting. Preoperative diagnosis is not easy. Oral endoscopy is one of the diagnostic procedures. We present a case in which the diagnosis was made by endoscopic examination. Multiple attempts at endoscopic extraction of the gallstone from the duodenum were unsuccessful. A one-stage surgical procedure consisting of the removal of the impacted stone, fistula repair, and cholecystectomy was performed in this case. The postoperative course was uneventful.     

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.     

Recurrent small bowel obstruction after laparoscopic surgery for gallstone ileus

Gallstone ileus is an uncommon cause of small bowel obstruction. A patient presenting with gallstone ileus was managed in our department by laparoscopic enterolithotomy. Postoperatively, the patient developed recurrent small bowel obstruction due to the presence of a second gallstone. It is therefore important to exclude the possibility of multiple gallstones at the initial operation.     

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.     

Bouveret's syndrome: a rare clinical variant of gallstone ileus

Bouveret's syndrome is a rare complication of gallstone disease characterized by gastric outlet obstruction due to impaction of single or multiple gallstones which have migrated through a bilio-enteric fistula. The main symptoms are nausea, vomiting and epigastric pain. The diagnosis is achieved by plain film of the abdomen, ultrasonography and CT scan, which reveal aerobilia (an indirect sign of bilio-enteric fistula), and the obstructing gallstone. The treatment of this condition requires removal of the stone through an endoscopic or surgical approach, and possible cholecystectomy with closure of the fistula. The Authors report a case of Bouveret's syndrome in an 86-year-old female patient who underwent successful surgical treatment.     

Bouveret's syndrome. An unusual localization of gallstone ileus

This case report describes a 77-year-old male, who presented to the emergency room with symptoms of an acute proximal small bowel obstruction. Abdominal CT scan with multi-planar reconstructions led to the diagnosis of an intestinal obstruction due to impaction of a large gallstone in the second portion of the duodenum. The CT scan demonstrated a large cholecysto-duodenal fistula as the origin of the gallstone migration. Surgical treatment consisted of milking the stone down beyond the ligament of Treitz, where it was removed through a jejunal enterotomy. The postoperative course was uncomplicated. No attempt was made to repair the choledocho-duodenal fistula at the initial intervention nor subsequently, and there have been no complications due to the fistula over 36 months of follow-up observation.     

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.     

Case report: Closed-loop bowel obstruction secondary to a double gallstone ileus

Introduction and importanceIn this paper, we report an unusual case of a closed-loop bowel obstruction secondary to a double gallstone ileus. This type of pathology constitutes an emergency, and requires prompt surgical intervention to prevent further complications.Presentation of caseThe patient was a 90-year-old female who came to our emergency room with a clinical picture compatible with an acute abdomen. Imaging tests performed included a plain radiograph and abdominal CT-scan, which confirmed the diagnosis. The patient was then transferred to the operating room, and an open double enterolithotomy was performed, extracting two cylindrical gallstones with a diameter of over 2.5 cm. No treatment was given for either the gallbladder nor the biliary-enteric fistula due to the patient's physical status.Clinical discussionGallstone ileus is a rare entity, but must be taken into consideration when a patient with an abdominal obstruction arrives to the emergency department, especially when signs such as pneumobilia or visualization of the stones are detected by imaging tests. Early surgical intervention is required to avoid complications. However, addressing the biliary-enteric fistula at the same time is a sensitive procedure that may not be advisable, depending on the status of the patient. This report includes a bibliographic review of existing cases of gallstone ileus and the specifics of its diagnosis and management.ConclusionThis pathology can lead to serious complications if not managed properly. Prompt diagnosis and surgical intervention are essential to avoid complications such as intestinal gangrene and perforation. Inspecting the entire intestine during surgery is crucial for removing any additional gallstones that may be present to prevent the reappearance of symptoms.     

Laparoscopic approach to small bowel obstruction

Historically, laparotomy and open adhesiolysis have been the treatment of choice for patients requiring surgery with small bowel obstruction (SBO), although laparotomy itself is an independent risk factor for bowel obstruction. Laparoscopy is known to create fewer intra-abdominal adhesions than open laparotomy. The observation that many patients with SBO have isolated adhesive bands has led to the use of laparoscopy as primary treatment of SBO by some authors. Although the laparoscopic approach to SBO has been described, the outcomes and indications are not well established. We will review the available literature regarding the laparoscopic approach to SBO. Additionally, we will describe the technique and make recommendations regarding which patients may be best suited for a trial of laparoscopy for adhesiolysis.     

Cholelithic small bowel obstruction

Results of treatment of 18 patients with cholelithic small bowel obstruction are analyzed. All of them were female aged 62 to 84 years with severe concomitant diseases. Different variants of clinical manifestation of small bowel obstruction, significance of diagnostic methods, the causes of delayed hospitalization and operation are analyzed in details. Fourteen patients have been operated with diagnosis of intestinal obstruction but only at 3 of them the true cause of disease has been assumed before surgery. Enterolithotomy was performed at 15 patients, resection of small intestine together with gallstone - at 3 patients. Recurrence of cholelithic obstruction was seen at one patient on 8th day after surgery. Postoperative lethality was 27.7%, but only at one case the purulent complications and multiple organ failure was the cause of lethality. Recommendations for improvement of treatment results and prophylaxis of cholelithic small bowel obstruction are given.     

Postlaparoscopic small bowel obstruction

Background: Patients with early postoperative small bowel obstruction (SBO) are usually managed nonoperatively with nasogastric suction, intravenous fluids, and observation. The majority of early postoperative SBO resolve without an operation. Methods: We performed a retrospective review of patients who had been diagnosed with postlaparoscopic SBO at three Chicago area teaching hospitals. Results: The patients were initially managed nonoperatively for up to 7 days. However, all of them subsequently required an operation. In every case, the postlaparoscopic SBO was caused by the small bowel being incarcerated in a peritoneal defect created either by trocar placement or peritoneal incision for herniorrhaphy. Conclusion: In contradistinction to the approach used for early SBO after laparotomy, prompt operative intervention for postlaparoscopic SBO is recommended.     

Antropyloric lithiasic obstruction. A variant of Bouveret's syndrome]

We report about one case of cholecystoduodenal fistula complicated by antropyloric lithiasic obstruction, which was treated surgically with gastrotomy and extraction of the calculus, in an 82-year-old woman. This case represents an anatomic variant of Bouveret's syndrome, which is classically defined as a duodenal lithiasic obstruction. On the basis of this case, the authors discuss the diagnostic and possibly therapeutic merits of digestive endoscopy and define the main clinical, anatomical and evolutive characteristics of this unfrequent complication of biliary lithiasis.     

Recurrent adhesive small bowel obstruction

Adhesive obstruction of the small bowel complicates about 5% of laparotomies; of these, 5–10% have recurrent attacks. The etiology of adhesions is incompletely understood and attempts to prevent their formation are of unproven value. Patients with recurrent acute obstruction that threatens strangulation, or that fails to subside, require laparotomy. If numerous adhesions have to be divided, it is worth considering a procedure to encourage fresh adhesions to form in a favorable pattern. Suture plication of the bowel by Noble's technique has a high incidence of complications and recurrent obstruction, and transmesenteric plication cannot be used in the presence of sepsis. Splinting of the entire small bowel by intraoperative passage of a long tube, which is left indwelling for 2–3 weeks, appears to be effective and safe. We have used this method in 140 patients without associated complications; of these, 17 had recurrent intestinal obstruction after 1–5 previous laparotomies for adhesions. A meticulous adhesiolysis followed by transluminal splinting through a jejunostomy has been followed by freedom from recurrence during 103 patient-years of follow-up.

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Resumen La obstrucción por adherencias es una complicación que ocurre en alrededor del 5% de las laparotomías, y de los pacientes que la desarrollan 5–10% sufren episodios recurrentes. La etiología de las adherencia no es totalmente conocida, y los intentos orientados a prevenir su formación han probado ser de utilidad no comprobada. Los pacientes con obstrucción aguda que presagia estrangulación o que no cede con un manejo de unos días de reposo intestinal y líquidos parenterales, requieren laparotomía. Cuando es necesario dividir numerosas adherencias, es Útil considerar la realización de un procedimiento que promueva la formación de adherencias frescas en un patrón ordenado y favorable. La plicación mediante suturas segÚn la técnica de Noble se acompaña de una elevada tasa de complicaciones y de obstrucción recurrente, y la plicación transmesentérica está contraindicada en presencia de sepsis. La fijación de la totalidad del intestino delgado mediante la colocación intraoperatoria de un tubo intestinal largo, el cual es dejado por 2–3 semanas, parece ser un método efectivo y seguro. Hemos utilizado tal método en 140 pacientes sin complicaciones; de éstos, 17 presentaban obstrucción recurrente después de 1–5 laparotomías previas por adherencias. La meticulosa lisis de las adherencias seguida de la fijación transluminal mediante tubo colocado a través de una yeyunostomía a 10–15 cm del ángulo duodenoyeyunal ha resultado en ausencia de recurrencia en 103 pacientes-año de seguimiento.

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Résumé L'occlusion de l'intestin grÊle secondaire à des adhérences complique environ 5% des laparotomies et récidive dans 5–10% des cas. L'étiologie précise des adhérences n'est pas parfaitement connue et toutes les méthodes de prévention qui ont été tentées n'ont pas fait leur preuve. Tous les malades qui présentent des attaques répétées et des menaces d'étranglement intestinal doivent Être opérés. Si les adhérences à lever sont très nombreuses il est nécessaire d'avoir recours à une méthode thérapeutique qui favorise la reconstitution en bon ordre de nouvelles adhérences. La plicature ordonnée des anses intestinales selon la technique de Noble est suivie de nombreuses complications et de récidive, la plicature transmésentérique selon la technique de Child ne peut Être employée en cas d'infection. C'est la raison pour laquelle il convient de substituer à ces modes de plicature, celle qui fait appel à un long tube intradigestif qui est laissé en place 2–3 semaines. La méthode est dénuée de danger et efficace. Elle a été employée chez 140 malades sans aucune complication alors mÊme que 17 d'entre eux présentaient des occlusions à répétition, et avaient subi de l à 5 laparotomies. Cette technique de libération des adhérences suivie de la plicature ordonnée des anses intestinales sur un tube introduit dans le grÊle par la voie d'une petite jéjunostomie a permis d'enregistrer l'absence de récidives de l'occlusion chez 103 malades qui ont été attentivement suivis.