De Backer, Adelard I

De Backer, Eva

Vanhoenacker, Filip

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De Backer, Adelard

Institutional Repository Universiteit Antwerpen

Case 14613 : cholecystoduodenal fistula with migrated gallstone leading to gastric outlet obstruction: Bouveret's syndrome

Ghent University Academic Bibliography

Case 14613 Cholecystoduodenal fistula with migrated gallstone leading togastric outlet obstruction: Bouveret's syndromeEva De Backer , Filip Vanhoenacker , Adelard De Backer1 2, 3, 4 51: Ghent University, Medical Student, De Pintelaan 185, 9000 Ghent, Belgium2: AZ Sint-Maarten Duffel-Mechelen, Department of Radiology, Leopoldstraat 2, 2800 Mechelen,Belgium3: Ghent University Hospital, Department of Radiology, De Pintelaan 185, 9000 Ghent, Belgium4: Antwerp University Hospital, Department of Radiology, Wilrijkstraat 10, 2650 Edegem, Belgium5: General Hospital Sint-Lucas, Department of Radiology, Groenebriel 1, 9000 Ghent, Belgium  Abdominal Imaging Section: 2017, Apr. 10 Published: 85 year(s), femalePatient:Clinical HistoryA 85-year-old woman presented with weight loss, abdominal pain, nausea and vomiting sinceseveral weeks. Physical examination revealed tenderness in the right upper quadrant. Blood analysisshowed a normal white blood cell count (5.2 x 103/µl) and a slightly elevated C-reactive protein(14.0 mg/l). Liver function tests were normal.Imaging FindingsComputed tomography (CT) of the abdomen showed a laminated gallstone in the neck of thegallbladder causing outlet obstruction, air in the gallbladder lumen, inflammatory thickening of thegallbladder and adjacent duodenum wall, and a large laminated gallstone in the gallbladder bodyprotruding into the duodenal bulb (Fig. 1 A, B and C). Upper gastrointestinal series showed contrastmedium surrounding the gallstone, indicating a gastroduodenal fistula, with impaction of a largegallstone in the duodenal bulb and delayed gastric emptying (Fig. 2 A and B).Oesophagogastroduodenoscopy showed a large stone in the duodenal bulb.DiscussionCholecystoduodenal fistula with gallstone migration leading to intestinal obstruction is a rarecomplication of gallstone disease. Gallstone disease with associated chronic inflammation of thebiliary system and adjacent bowel wall may cause local ischemia and necrosis of adherent walls,resulting in fistula formation. The gallstone may migrate into the bowel lumen [1]. In most patientswith biliary-enteric fistula, the fistula communicates with the duodenum and stones, usually lessthan 2.5 cm, will pass spontaneously without causing bowel obstruction. Larger stones may result inbowel obstruction [2]. In descending order of frequency, the gallstone may be lodged in theterminal ileum, proximal ileum, distal jejunum, colon, and duodenum or stomach. When thegallstone lodges in the duodenum or stomach leading to gastric outlet obstruction it is namedBouveret's syndrome (occurring in 1-3% of gallstone ileus) [3].Bouveret's syndrome occurs more frequently in elderly women with a history of biliary disease. Theclinical symptoms may be nonspecific including nausea and vomiting, abdominal pain,hematemesis, anorexia and recent weight loss [2, 4]. Early diagnosis is important because themortality rate is high [1]. Radiographic features of gallstone ileus are the classical Rigler's triad consisting of pneumobilia,dilated bowel loops and an ectopic gallstone. This triad is easily recognized on contrast-enhancedCT [5]. In this case, CT shows pneumobilia and a large ectopic gallstone protruding into theduodenal bulb causing gastric outlet obstruction. CT is the preferred imaging method for thediagnosis of Bouveret's syndrome [3]. Other imaging methods are ultrasonography, MRCP andoesophagogastroduodenoscopy, with the latter being both diagnostic and therapeutic [3].A minimal invasive approach such as endoscopic stone removal has been proposed as a first-linetreatment of Bouveret's syndrome. However the success rate of endoscopic treatment is low [3, 4,5]. Therefore, surgery remains the mainstay of treatment. There are two main surgical approaches.In this case, urgent cholecystotomy with stone removal and closure of the gallbladder wall wasperformed. The cholecystoduodenal fistula was left unchanged. A cholecystectomy and fistulaclosure will be planned at a later date. This two-staged procedure is the preferred strategy forpatients in a critical condition or with significant comorbidities. The other approach is a one-stageprocedure, which combines enterolithotomy, cholecystectomy, and fistula closure [5]. Bouveret's syndrome represents an unusual variant of gallstone ileus. Bouveret's syndrome shouldbe considered in the differential diagnosis in patients with gallstone disease presenting gastric outletobstruction.Final DiagnosisBouveret's syndromeDifferential Diagnosis ListCauses of gastric outlet obstruction: Malignant tumor (gallbladder carcinoma; cholangiocarcinoma;adenocarcinoma of the duodenum and pancreas; GIST; lymphoma; metastasis);  Benign mass(gastric bezoar); Inflammatory disorder (peptic disease; Crohn's disease), Causes of pneumobilia:Infectious disease (cholangitis; emphysematous cholecystitis; liver abscess);  Biliary-enteric fistula(peptic disease; traumatic; malignant)FiguresFigure 1 Computed tomography image showing Rigler's triadContrast-enhanced axial CT image shows subtle gastric distention secondary to impaction ofa gallstone in proximal duodenum. A stone is noted in the neck (open arrow), and in thebody of the gallbladder (closed arrow). © De Backer A, Department of Radiology, General Hospital Sint-Lucas, Groenebriel 1, 9000 Ghent, Belgium Area of Interest: Abdomen;  Imaging Technique: CT;  Procedure: Diagnostic procedure;  Special Focus: Fistula; Contrast-enhanced CT image obtained caudal to A shows pneumobilia in a partiallycontracted gallbladder. The gallbladder seems to communicate directly with adjacentduodenum and a large laminated gallstone is abutting the duodenal bulb (arrow). © De Backer A, Department of Radiology, General Hospital Sint-Lucas, Groenebriel 1, 9000 Ghent, Belgium Area of Interest: Abdomen;  Imaging Technique: CT;  Procedure: Diagnostic procedure;  Special Focus: Fistula; Contrast-enhanced oblique reformatted CT image shows stone in the neck (small openarrow) and body (large open arrow) of the gallbladder. Adjacent a cholecystoduodenal fistulawith stone migration into the duodenum is noted (closed arrow). © De Backer A, Department of Radiology, General Hospital Sint-Lucas, Groenebriel 1, 9000 Ghent, Belgium Area of Interest: Abdomen;  Imaging Technique: CT;  Procedure: Diagnostic procedure;  Special Focus: Fistula; Figure 2 Upper gastrointestinal series.Upper gastrointestinal series show a large stone surrounded by contrast agent in duodenalbulb, resulting in partial gastric outlet obstruction (arrow). © De Backer A, Department of Radiology, General Hospital Sint-Lucas, Groenebriel 1, 9000 Ghent, Belgium Area of Interest: Abdomen;  Imaging Technique: CT;  Procedure: Diagnostic procedure;  Special Focus: Fistula; Upper gastrointestinal series show a cholecystoduodenal fistula and partial filling of thegallbladder (open arrow). The filling defect in the gallbladder is caused by a gallstone(closed arrow). © De Backer A, Department of Radiology, General Hospital Sint-Lucas, Groenebriel 1, 9000 Ghent, Belgium Area of Interest: Abdomen;  Imaging Technique: CT;  Procedure: Diagnostic procedure;  Special Focus: Fistula; References[1] Nickel F, Müller-Eschner MM, Chu J, von Tengg-Kobligk H, Müller-Stich BP (2013)Bouveret's syndrome: presentation of two cases with review of the literature and development of asurgical treatment strategy BMC Surg 13:33[2] Singh AK, Shirkhoda A, Lal N, Sagar P (2003) Bouveret's syndrome: appearance on CT andupper gastrointestinal radiography before and after stone obturation Am J Roentgenol181(3):828-830[3] Kalwaniya DS, Arya SV, Guha S, Kuppuswamy M, Chaggar JG, Lalmalsamwe R, Chejera R,Sharma A (2015) A rare presentation of gastric outlet obstruction (GOO) - The Bouveret'ssyndrome Ann Med Surg (Lond) 4(1):67-71[4] Cappel MS, Davis M (2006) Characterization of Bouveret's Syndrome: a comprehensive reviewof 128 Cases Am J Gastroenterol 101(9):2139-2146[5] Nabais C1, Salústio R, Morujão I, Sousa FV, Porto E, Cardoso C, Fradique C (2013) Gastricoutlet obstruction in a patient with Bouveret's syndrome: a case report BMC Res Notes 6:195CitationEva De Backer , Filip Vanhoenacker , Adelard De Backer1 2, 3, 4 51: Ghent University, Medical Student, De Pintelaan 185, 9000 Ghent, Belgium2: AZ Sint-Maarten Duffel-Mechelen, Department of Radiology, Leopoldstraat 2, 2800 Mechelen,Belgium3: Ghent University Hospital, Department of Radiology, De Pintelaan 185, 9000 Ghent, Belgium4: Antwerp University Hospital, Department of Radiology, Wilrijkstraat 10, 2650 Edegem, Belgium5: General Hospital Sint-Lucas, Department of Radiology, Groenebriel 1, 9000 Ghent, Belgium(2017, Apr. 10) Cholecystoduodenal fistula with migrated gallstone leading to gastric outlet obstruction: Bouveret's syndrome {Online}URL: http://www.eurorad.org/case.php?id=14613

Cholecystoduodenal fistula with migrated gallstone leading to gastric outlet obstruction : Bouveret's syndrome

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Cholecystoduodenal fistula with migrated gallstone leading to gastric outlet obstruction : Bouveret's syndrome

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