Single-stage laparoscopic management of gallstone ileus with concurrent Bouveret syndrome: a case report

Bouveret syndrome is a rare (0.3-0.5%) form of gallstone ileus caused by gallstone impaction in the duodenum via a cholecystoenteric fistula. Its nonspecific presentation and high mortality rate (12-30%) make early diagnosis and appropriate management essential. Dual gallstone impaction - combining Bouveret syndrome with distal small bowel obstruction - is even more uncommon and poses additional diagnostic and therapeutic challenges.

A 55-year-old woman with a 3-year history of gallstones and partially controlled type 2 diabetes presented with persistent epigastric pain, non-bilious vomiting, and oral intolerance. Contrast-enhanced abdominal computed tomography (CT) identified dual gallstone impaction: a 25-mm gallstone lodged within a cholecystoduodenal fistula, causing gastric outlet obstruction, and a 30-mm gallstone impacted in the proximal jejunum. The patient underwent emergency single-stage laparoscopic surgery, including partial cholecystectomy, fistula repair, and enterolithotomy, achieving full resolution of both obstructions without complications.

This case demonstrates the diagnostic value of CT imaging in identifying both a cholecystoduodenal fistula and simultaneous small bowel obstruction, enabling timely surgical planning. While endoscopic and open surgical options exist, this case illustrates that a laparoscopic single-stage approach is feasible even in complex cases of gallstone ileus with dual gallstone impaction.

Laparoscopic single-stage surgery is a safe and effective option for managing Bouveret syndrome with concurrent jejunal gallstone obstruction. Early CT-based diagnosis and multidisciplinary assessment remain key to optimizing outcomes. The patient remained asymptomatic at the 1-month follow-up, with imaging confirming fistula closure and no residual stones.