Bouveret Syndrome

Gastric outlet obstruction caused by a large gallstone blocking the pylorus or duodenum.

Unknown; fewer than 200 cases reported.

Acquired condition.

Acute cholecystitis results in adhesion formation between the gallbladder and intestine. The large gallstone causes ischemia of the cystic wall. Necrosis results, allowing passage of the stone through a cholecystenteric fistula to any adherent bowel but, in more than 66% of the cases, to the duodenum. However, duodenal obstruction constitutes only 3% of all cases of gall-stone ileus.

Usually made during operation but more recently at endoscopy or on CT scan. The diagnosis is supported by air in the biliary tree in the presence of a gastric outlet obstruction.

History of cholecystitis is present in approximately half of patients. Signs and symptoms are those of small bowel obstruction, nausea, vomiting, epigastric pain, and abdominal distension. Only 50 to 70% of patients present with the characteristic features of intestinal obstruction, which may result from continuous impacting and disimpacting of the stone during its passage distally. Relief of symptoms after the stone becomes mobile again may suggest gastroenteritis, especially with the common finding of diarrhea. However, as the diameter of the small bowel becomes smaller distally and the gallstone bigger by accumulation of intestinal contents, the impaction finally is complete and irreversible. Approximately 66% of all impacted gallstones are found in the ileum; only approximately 4% successfully pass the ileocecal valve and cause colonic obstruction. Gastrointestinal hemorrhage may occur from duodenal ulceration or erosion of cystic artery (one case). Vomiting leads to dehydration and electrolyte disturbances (hypochloremic, hypokalemic metabolic alkalosis). Anemia may be present as a consequence of occult loss or gastrointestinal hemorrhage.

Check volume status and correct hypovolemia, hemoglobin, electrolytes, and acid-base status preoperatively. Investigate coexisting diseases as indicated. Pass a nasogastric tube, which can be removed for induction, to decompress the stomach.

Ileus and full stomach. Aspirate nasogastric tube prior to rapid sequence induction. High abdominal incision in patients with preexisting lung disease predisposes to postoperative pulmonary complications; thoracic epidural analgesia may be advantageous. Consider other therapeutic options, such as endoscopic stone removal, endoluminal YAG-laser lithotripsy, or extracorporal shockwave lithotripsy.

No known specific implications.