Presentation
History of nausea, multiple bilious vomiting episodes, anorexia, discomfort in RUQ and epigastrium, and fever up to 38.7°C for 2 days.
Patient Data
Abdominal plain radiograph shows evidence of pneumobilia and radio-opaque shadow over the right iliopsoas muscle.
Non-contrast-enhanced CT of the abdomen shows the presence of gas in the left intrahepatic bile duct and CBD - pneumobilia.
The gallbladder cannot be well defined, no wall is seen, presence of free intramural, pericholecystic fat stranding findings consistent with Gangrenous cholecystitis. There is a cholecystenteric fistula between the body and the 2nd portion of the duodenum with impacted stone measuring about 45mm in diameter - Bouveret syndrome
Additional findings include placement of a nasogastric tube in the stomach. Colonic diverticulosis and a previous hysterectomy as well as fixation from femoral cervix fracture on the right hip.
Red arrow points the Cholecystoduodenal fistula.
Green arrow shows A gallstone in the 1st to 2nd part of the duodenum.
Yellow arrow indicates the Pneumobilia.
Emergency laparotomy with Cholecystectomy was done. The surgical report showed disruptive calculus cholecystitis, a cholecystoduodenal fistula with impacted gallstone measuring about 5x5 cm diameter in the descending part of the duodenum obstructing its lumen. Subserotic cholecystectomy and excision of the fistula and extraction of the gallstone from the duodenum were performed.
The image above shows the removed gallstone.
Case Discussion
Bouveret syndrome is a rare form of gallstone ileus caused by the passage and impaction of a large gallstone through a cholecystoduodenal fistula into the duodenum. In 1896 the French physician Leon Bouveret published two cases of gastric outlet obstruction due to gallstone stranding in the duodenal bulb. It most commonly affects elderly women with a mean age of 68.6 years. The presenting clinical situation is variable and nonspecific but often includes nausea, bilious vomiting, and epigastric pain.
The most common CT findings include pneumobilia, gallstone impacted in the proximal portion of the duodenum and distended stomach (not shown here due to the presence of nasogastric-tube).
If the patient has no other complications Endoscopy is a preferred method of choice of removing the impacted stone. As in our case combined with cholecystitis surgical treatment is required.
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