Cholecystogastric fistula presenting as pyloric obstruction - a Bouveret's syndrome: A case report.

Abstract

Background: Bouveret's syndrome is a rare (1%-4%) form of cholelithiasis characterized by gastric outlet obstruction. It presents mainly in elderly women with nausea, vomiting, and abdominal pain. On physical examination, common findings include dehydration signs such as tachycardia, decreased urine output, abdominal discomfort, and distention. Diagnosis relies on computed tomography (CT) and magnetic resonance imaging, with Rigler's triad (pneumobilia, ectopic gallstone, gastric distension) being highly specific. This report aims to improve understanding of Bouveret's syndrome and inform better management and treatment strategies.

Case summary: A 60-year-old male patient presented with a three-day history of nausea, vomiting, upper abdominal pain, and loss of appetite. An upright abdominal X-ray revealed a gas shadow in the intrahepatic and extrahepatic bile ducts. Endoscopy revealed a brown and black stone measuring approximately 3030 mm in diameter in the gastric pylorus, incompletely obstructing the gastric outlet. The diagnosis of Bouveret's syndrome was accurately confirmed via an abdominal CT scan. Endoscopic removal of the stone was successful, owing to the stone being fragmented and extracted in pieces using a crushing basket. Three weeks later, laparoscopy was attempted but failed because of severe tissue adhesions. Consequently, the procedure was converted to a laparotomy, and fistula repair and cholecystectomy were performed. He returned to the outpatient clinic for follow-up, and no further concerns were noted.

Conclusion: This case highlights the importance of timely diagnosis and adaptable endoscopic and surgical approaches for effectively managing Bouveret's syndrome.