Bouveret syndrome: proximal bowel obstruction by a gall stone-case report

Bouveret syndrome is gastric outlet obstruction due to gallstone impaction in the proximal small bowel. Diagnosis is often difficult due to its rare occurrence and vague presentation. The associated high morbidity and mortality in elderly patients necessitates early diagnosis and tailored management.

A 59-year-old female presented with sudden onset severe abdominal pain and bilious vomiting for 7 days. With a diagnosis of acute calculous cholecystitis, she was taken up for laparoscopic surgery, which was abandoned in view of dense adhesions between gallbladder and duodenum. On referral to our institute, further evaluation abdomen revealed acute calculous cholecystitis with suspicion of sealed off gallbladder perforation and a cholecysto-duodenal fistula, which was confirmed at laparotomy. Cholecystectomy was performed, and the fistula was taken down. Incidentally, a large gallstone was noted impacted in the proximal jejunum, which was removed via an enterotomy. Patient had an uneventful recovery.

Our patient, an elderly hypertensive female, presented with abdominal pain, bilious vomiting, and constipation, and was found to have a gallstone impacted in the proximal jejunum - an unusual site for impaction. CT imaging revealed a cholecysto-duodenal fistula. A one-stage procedure with surgical enterotomy and stone retrieval, with simultaneous cholecystectomy and fistula takedown was tolerated well, with an uneventful postoperative course.

A high index of suspicion and early surgical intervention are keys to successful management of this infrequent clinical entity.