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At a glance

Gastric or duodenal outlet obstruction caused by a large gallstone blocking the pylorus or duodenum.

History

The first description is credited to the French surgeon M. Beaussier who reported this disease in 1770. However, it bears the name of the French internist Léon Auguste Bouveret (1850-1929), who reported on two cases in 1896.

Incidence

Unknown. Approximately 300 cases have been reported.

Genetic inheritance

No genetic background, this is an acquired condition.

Pathophysiology

Complications from cholelithiasis include acute cholecystitis, choledocholithiasis, pancreatitis, and gallstone ileus. Acute cholecystitis may result in the development of adhesions between the gallbladder and adjacent intestinal structures. The presence of a large gallstone can cause ischemia of the inflamed gallbladder wall with subsequent necrosis and perforation, allowing the passage of the stone through a cholecystogastric or cholecystoenteric fistula into any adherent bowel loops, but in over two-third of cases, the stone passes into the duodenum. However, duodenal obstruction accounts for less than 10% of all gallstone ileus cases. The most common site of obstruction is the distal ileum (up to 65% of gallstone ileus), followed by the jejunum (16%), and the stomach (14%), while colon and sigmoid are affected in less than 5% each. In classical Bouveret Syndrome, the gallstone ileus is caused by an outlet obstruction of the stomach.

Diagnosis

The diagnosis of this condition is not always straightforward due to sometimes unspecific and subtle initial symptoms and having a high level of suspicion in patients with a history of cholelithiasis is key. Beside the clinical symptoms of obstructive gastric ileus, the diagnosis nowadays is mainly made by endoscopy, abdominal ultrasound, and/or x-ray and/or CT-scan. While upper endoscopy has a very high success rate in diagnosing the mechanical obstruction, it fails to correctly identify an impacted gallstone as the cause in almost one-third of patients (as the stone can be deeply embedded within the mucosa and blood and clots may obstruct the view). A diagnostic aid is the presence of Rigler’s triad on plain abdominal x-ray films, consisting of a dilated stomach, pneumobilia (air in the biliary tree) and a radio-opaque shadow in the region of the duodenum representing the migrated gallstone. If further migration of the gallstone can be detected on follow up x-ray films, then this completes Rigler’s tetrad.

Clinical aspects

A history of cholecystitis is present in approximately half of patients. Signs and symptoms are those of upper gastrointestinal obstruction with nausea, vomiting (in almost 90% of patients), epigastric pain or abdominal tenderness (in 71%), abdominal distension (in 26%), dehydration (in 31%), hematemesis (in 15%), melena (in 6%), and fever (in 13%). Occasionally, a history of recent weight loss (in 14%) and anorexia (in 13%) is found. Nevertheless, a fair number of ...

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