Endoscopy 2013; 45(S 02): E231-E232
DOI: 10.1055/s-0033-1344324
Cases and Techniques Library (CTL)
© Georg Thieme Verlag KG Stuttgart · New York

Proximal duodenal obstruction – Bouveret’s syndrome revisited

C. R. Werner
1  Department of Gastroenterology, Hepatology, and Infectious diseases, University Hospital Tübingen, Medical Clinic, Tübingen, Germany
,
F. Graepler
1  Department of Gastroenterology, Hepatology, and Infectious diseases, University Hospital Tübingen, Medical Clinic, Tübingen, Germany
,
J. Glatzle
2  Department of General, Visceral, and Transplant Surgery, University Hospital Tübingen, Tübingen, Germany
,
D. Stüker
2  Department of General, Visceral, and Transplant Surgery, University Hospital Tübingen, Tübingen, Germany
,
T. Kratt
2  Department of General, Visceral, and Transplant Surgery, University Hospital Tübingen, Tübingen, Germany
,
J. Schmehl
3  Department of Diagnostic and Interventional Radiology, University Hospital Tübingen, Tübingen, Germany
,
M. Bitzer
1  Department of Gastroenterology, Hepatology, and Infectious diseases, University Hospital Tübingen, Medical Clinic, Tübingen, Germany
,
A. Königsrainer
2  Department of General, Visceral, and Transplant Surgery, University Hospital Tübingen, Tübingen, Germany
,
N. P. Malek
1  Department of Gastroenterology, Hepatology, and Infectious diseases, University Hospital Tübingen, Medical Clinic, Tübingen, Germany
,
M. Goetz
1  Department of Gastroenterology, Hepatology, and Infectious diseases, University Hospital Tübingen, Medical Clinic, Tübingen, Germany
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Corresponding author

C. R. Werner, MD
University Hospital Tübingen, Medical Clinic
Department of Gastroenterology, Hepatology, and Infectious diseases
Otfried-Mueller-Str. 10
D-72076 Tübingen
Germany   
Fax: +49-7071-295906   

Publikationsverlauf

Publikationsdatum:
14. August 2013 (online)

 

A 62-year-old man presented to our emergency department with acute epigastric pain and vomiting. He was found to have elevated markers of inflammation with a white cell count of 16.1 × 109/L and C-reactive protein (CRP) of 30 mg/L (normal < 5 mg/L), impaired renal function with a creatinine of 1.8 mg/dL, and evidence of mild cholestasis with a bilirubin of 1.3 mg/dL and γ-glutamyltransferase (GGT) of 78 IU/L.

Esophagogastroduodenoscopy (EGD) showed grade 3 reflux esophagitis, and 3 L of gastric fluid were aspirated. Passage of the endoscope beyond the pylorus was obstructed by a mass covered with creamy pus ([Fig. 1 a, b]). After the area had been thoroughly flushed, an incarcerated gallstone was found, which was occluding the duodenal bulb with the orifice of the fistula moving relative to the gallstone ([Fig. 1 c]). Endoscopic retrieval (by net, balloon, and snare) failed because of the large diameter of the stone. Computed tomography (CT) scanning revealed an air crescent within the gallbladder and a penetrating gallstone of 3 cm located within the duodenum, which was completely obliterating the lumen ([Fig. 2]), but there were no signs of intra-abdominal perforation.

Zoom Image
Fig. 1 Endoscopic transpyloric views showing: a the mass that was obstructing the duodenal bulb; b the mass in close-up view; c the incarcerated gallstone and the orifice of the fistula (arrows), which are visible after thorough flushing of the area.
Zoom Image
Zoom Image
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Fig. 2 Computed tomography (CT) scan showing the gallstone that had penetrated into the duodenum (arrow) and an air crescent in the gallbladder (arrowhead).

During surgery, the penetration of the gallstone through a cholecystoduodenal fistula was confirmed ([Fig. 3]). The large stone could only be removed after fragmentation ([Fig. 4]). Local excision of the fistula tract was performed and the operation was completed by a cholecystectomy. The patient was discharged from hospital a few days later. On follow-up 3 months later, he had no specific complaints.

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Fig. 3 Photograph taken during surgery showing the cholecystoduodenal fistula with the cystic (arrowhead) and duodenal (arrow) sections visible. The brownish gallstone is also still in situ.
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Fig. 4 Photograph of the fragmented gallstone after removal.

Proximal ileus caused by penetration of a large gallbladder stone is a rare clinical entity that was first described in 1896 by Bouveret [1], but has only rarely been reported since [2]. If technically feasible, endoscopic retrieval and spontaneous regression of the fistula tract have been reported [3] and this approach may be appropriate, especially in older patients or those with comorbidities, if close interdisciplinary follow-up is provided. However, surgical removal of the stone is often the more appropriate solution.

Endoscopy_UCTN_Code_CCL_1AB_2AZ_3AZ


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Competing interests: None


Corresponding author

C. R. Werner, MD
University Hospital Tübingen, Medical Clinic
Department of Gastroenterology, Hepatology, and Infectious diseases
Otfried-Mueller-Str. 10
D-72076 Tübingen
Germany   
Fax: +49-7071-295906   


Zoom Image
Fig. 1 Endoscopic transpyloric views showing: a the mass that was obstructing the duodenal bulb; b the mass in close-up view; c the incarcerated gallstone and the orifice of the fistula (arrows), which are visible after thorough flushing of the area.
Zoom Image
Zoom Image
Zoom Image
Fig. 2 Computed tomography (CT) scan showing the gallstone that had penetrated into the duodenum (arrow) and an air crescent in the gallbladder (arrowhead).
Zoom Image
Fig. 3 Photograph taken during surgery showing the cholecystoduodenal fistula with the cystic (arrowhead) and duodenal (arrow) sections visible. The brownish gallstone is also still in situ.
Zoom Image
Fig. 4 Photograph of the fragmented gallstone after removal.