Bouveret’s Syndrome Due to Cholecystoduodenal Fistula

Case History: A 44-year-old female admitted with severe, colicky right upper quadrant pain radiating through to her back and one episode of vomiting of gallstones.

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Figure 1: CT: Axial contrast-enhanced CT scan image showing distended, thickened gallbladder wall, air foci and contrast within the lumen.

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Figure 2: CT: Coronal reformatted contrast-enhanced CT scan showing distended, thickened gallbladder wall, air foci and contrast within the lumen.

Diagnosis: Bouveret’s syndrome due to cholecystoduodenal fistula

Discussion: Bouveret’s syndrome was first described by Beaussier in 1770 but was subsequently named after Leon Bouveret. Due to the rarity and non-specific clinical symptoms and signs, the diagnosis can often be overlooked. The most common presenting features include nausea and vomiting, abdominal pain, haematemesis, recent weight loss and anorexia. The major complications of this syndrome are intestinal obstruction and haemorrhage.

In our case, the patient presented to us with biliary colic and a very unusual presentation of gallstone emesis. On X-ray we see pneumobilia, calcified gallstone, gastric distension, dilated bowel loops, features of duodenal or pyloric obstruction and air in gallbladder fossa, Rigler’s triad (small bowel obstruction, ectopic gallstones and pneumobilia). Eosophagogastroduodenoscopy has been shown to be diagnostic in 69% of cases.

Management is most commonly by enterolithotomy or gastrotomy with or without cholecystectomy and fistula repair with a high-success rate. The first endoscopic retrieval was successfully performed in 1985 by Bedogni et al. Endoscopic retrieval has a relatively low-success rate but with advancements in technology and endoscopic techniques, success rates have increased now and it is useful as an alternative therapy for patients not fit for surgery.

Alternative options for management of this entity include endoscopic laser, mechanic lithotripsy or extracorporeal shock-wave lithotripsy. The main drawbacks of these techniques are risk of converting a proximal gallstone ileus into a distal gallstone ileus by fragmentation of the stone. In most cases, fistula repair is deemed unnecessary because the fistula may spontaneously close especially if no residual gallstones are present and the cystic duct remains patent.

Binit Sureka, MD, DNB, Senior Resident, and Rohini Gupta, MD, Associate Professor
Department of Radiodiagnosis and Imaging
Vardhman Mahavir Medical College and Safdarjung Hospital
New Delhi, India