Bouveret syndrome

Case contributed by Ryan Thibodeau


Progressively worsening epigastric abdominal pain associated with abdominal tenderness to palpation, nausea, and vomiting.

Patient Data

Age: 65 years
Gender: Male

The gallbladder is enlarged. Within its lumen, there are multiple, large areas of hypoattenuation which likely represent gallstones. Within the most anterior gallstone, there is a small focus of hypoattenuation which may represent gas-fissuring.


Again seen is a large gallbladder with multiple large, hypoattenuating gallstones. There is a cholecystoduodenal fistula and an almost inseparable gallbladder and duodenum. There is pneumobilia in the left lobe of the liver and foci of air seen within the gallbladder.

The stomach is moderately dilated and predominantly fluid-filled.


Gallbladder/biliary tree:
The gallbladder is enlarged with a diffusely thickened wall measuring up to 0.6 cm. There is a small amount of T2 bright fluid which surrounds the gallbladder. There are at least two large T2 dark filling defects within the gallbladder, the largest measuring at least 4.7 cm, which likely represent large gallstones. The dilated gallbladder containing gallstones lies in the expected position of the first and second duodenum, and appears inseparable from the duodenum.

Again noted is a small amount of pneumobilia within the intrahepatic bile ducts to the left lobe, as seen by T2 dark filling defects in the nondependent portion of the biliary tree. There is moderate intrahepatic biliary ductal dilatation, with abrupt tapering at the level of the dilated gallbladder.

There is moderate dilatation of stomach containing air-fluid levels.

Mildly enlarged measuring 13.6 cm. There are multiple small circumscribed T2 hyperintense lesions throughout the spleen with circumscribed margins. These lesions demonstrate filling in on delayed phase imaging, likely representing splenic hemangiomas.

Case Discussion

This is a case of Bouveret's syndrome (gastric outlet obstruction due to an impacted gallstone in either the pylorus or proximal duodenum), which is seen on both CT and MRI in this case.

Operative notes indicate that as an endoscope was advanced into the stomach, a large stone was seen within the lumen of the duodenal bulb. Given the size, it was not amendable to endoscopic retrieval. The case was converted to an open gastrotomy with extraction of three gallstones >5 cm each. The patient did well post-operatively. and was discharged 1 week after the surgery.

Christine Cooley, MD

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