A Case of Bouvere't Syndrome

Abstract

An 85-year-old woman who had cholecystolithiasis was admitted to our hospital because of sudden onset of vomiting. She complained of upper abdominal fullness and right hypochondralgia but had no anemia, icterus or pyrexia. Endoscopic examination of the upper gastrointestinal tract showed pyloric stenosis due to the impacted stone. Abdominal ultrasonography revealed gallbladder wall thickening and pneumobilia. Abdominal CT revealed a 4-cm gallstone at the duodenal bulb. The gallbladder and duodenal bulb could not be separated as distinct structtures on CT. An upper gastrointestinal tract series demonstrated partial obstruction by the radiolucent gallstone in the duodenal bulb with reflux of balium into the gallbladder. Laparotomy was performed under a diagnosis of pyloric obstruction due to the impacted stone, namely Bouveret's syndrome. After the severely atrophic gallbladder and duodenal bulb was separated, a 4×3×3-cm gallstone was extracted from a dilated fistula of the duodenal bulb. We performed pyloroplasty by the Heineke-Mikulicz method, and no biliary radical operation was carried out. The patient had acute heart failure during the postoperative course but soon she recovered and was discharged on postoperative day 17. Duodenal bulb obstruction by a gallstone is an uncommon cause of gallstone ileus that is a rare complication of cholelithiasis. This paper describes a case of Bouveret's syndrome with a review of 12 cases in the Japanese literature over the last 21 years.