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Gastric or duodenal outlet obstruction caused by a large gallstone blocking the pylorus or duodenum.
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The first description is credited to the French surgeon M. Beaussier who reported this disease in 1770. However, it bears the name of the French internist Léon Auguste Bouveret (1850-1929), who reported on two cases in 1896.
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Unknown. Approximately 300 cases have been reported.
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No genetic background, this is an acquired condition.
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Complications from cholelithiasis include acute cholecystitis, choledocholithiasis, pancreatitis, and gallstone ileus. Acute cholecystitis may result in the development of adhesions between the gallbladder and adjacent intestinal structures. The presence of a large gallstone can cause ischemia of the inflamed gallbladder wall with subsequent necrosis and perforation, allowing the passage of the stone through a cholecystogastric or cholecystoenteric fistula into any adherent bowel loops, but in over two-third of cases, the stone passes into the duodenum. However, duodenal obstruction accounts for less than 10% of all gallstone ileus cases. The most common site of obstruction is the distal ileum (up to 65% of gallstone ileus), followed by the jejunum (16%), and the stomach (14%), while colon and sigmoid are affected in less than 5% each. In classical Bouveret Syndrome, the gallstone ileus is caused by an outlet obstruction of the stomach.
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The diagnosis of this condition is not always straightforward due to sometimes unspecific and subtle initial symptoms and having a high level of suspicion in patients with a history of cholelithiasis is key. Beside the clinical symptoms of obstructive gastric ileus, the diagnosis nowadays is mainly made by endoscopy, abdominal ultrasound, and/or x-ray and/or CT-scan. While upper endoscopy has a very high success rate in diagnosing the mechanical obstruction, it fails to correctly identify an impacted gallstone as the cause in almost one-third of patients (as the stone can be deeply embedded within the mucosa and blood and clots may obstruct the view). A diagnostic aid is the presence of Rigler’s triad on plain abdominal x-ray films, consisting of a dilated stomach, pneumobilia (air in the biliary tree) and a radio-opaque shadow in the region of the duodenum representing the migrated gallstone. If further migration of the gallstone can be detected on follow up x-ray films, then this completes Rigler’s tetrad.
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A history of cholecystitis is present in approximately half of patients. Signs and symptoms are those of upper gastrointestinal obstruction with nausea, vomiting (in almost 90% of patients), epigastric pain or abdominal tenderness (in 71%), abdominal distension (in 26%), dehydration (in 31%), hematemesis (in 15%), melena (in 6%), and fever (in 13%). Occasionally, a history of recent weight loss (in 14%) and anorexia (in 13%) ...