AJR 2003; 181:828-830
© American Roentgen Ray Society
Bouveret's Syndrome: Appearance on CT and Upper Gastrointestinal Radiography Before and After Stone Obturation
Ajay K. Singh1,2,
Ali Shirkhoda1,
Nirish Lal1 and
Pallavi Sagar3
1 Department of Diagnostic Radiology, William Beaumont Hospital, 3601 W. 13 Mile
Rd., Royal Oak, MI 48073.
3 Department of Internal Medicine, Long Island College Hospital, Brooklyn, NY
11201.
Received October 7, 2002;
accepted after revision January 14, 2003.
Address correspondence to A. K. Singh.
2 Present address: Department of Abdominal Imaging and Interventional
Radiology, Massachusetts General Hospital, White 270, 55 Fruit St., Boston, MA
02114-9657.
Introduction
Gastric outlet obstruction caused by gallstones was first described by
Léon Bouveret in 1896
[1]. This syndrome is most
common in elderly women with a history of biliary disease. The diagnosis of
Bouveret's syndrome is usually made with endoscopy, and less often with upper
gastrointestinal radiography, CT, or serial radiography
[2,
3,
4,
5,
6]. The migration of a
gallstone on follow-up radiographs can also be helpful in making this
diagnosis.
Gallstone ileus is mainly treated with surgery, either enterolithotomy or
gastrostomy, although some cases are treated with endoscopic extraction.
Cholecystectomy is not mandatory.
The literature contains only a few case reports of the CT appearance of
gallstone ileus [2,
3,
4,
7,
8]. In this case report, we
describe the serial findings on CT and upper gastrointestinal radiography
performed 2 months apart.
Case Report
A 79-year-old woman presented to the emergency department with acute chest
pain, and she had experienced dysphagia while eating chicken. Endoscopy
performed by a gastroenterologist showed acute esophageal mucosal ulceration
and impacted meat 30 cm from the incisors. The meat was broken with a
multibite forceps, and the obstruction relieved. On endoscopy, the gastric
antrum was found to be nonpliable, and the diagnosis of pyloric stenosis was
made. The scope was passed into the duodenum, where no obvious lesion could be
seen. No intraluminal gallstone was noted at this difficult endoscopic
evaluation of the duodenum, and therefore the diagnosis of Bouveret's syndrome
was not entertained.
Enhanced CT using IV but no oral contrast material showed pneumomediastinum
from esophageal perforation, gallbladder wall thickening, pneumobilia, and a
gallstone abutting the duodenal bulb (Figs.
1A and
1B). Upper gastrointestinal
radiography showed an irregular extrinsic impression from the gallbladder
without gastric outlet obstruction (Fig.
1A). This fnding did not show any obvious communication between
the duodenal bulb and the gallbladder.
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Fig. 1A. —79-year-old woman with Bouveret's syndrome. Upper
gastrointestinal radiograph obtained on first admission shows irregular
extrinsic impression (arrows) of orthotopic gallstone on duodenal
bulb. Note lack of obvious biliary-enteric fistula.
|
|
The patient's esophageal perforation and pneumomediastinum were
conservatively managed, and she fully recovered.
Two months later, the patient was readmitted because she experienced right
upper quadrant pain, nausea, and vomiting for 1 day. On physical examination,
she had tenderness in the right upper quadrant but no jaundice. Blood analysis
showed leukocytosis (WBC, 11.4 x 103/µL) with neutrophilia
and normal findings on liver function tests.
The patient again underwent enhanced CT and upper gastrointestinal
radiography. The upper gastrointestinal radiography findings were consistent
with a diagnosis of Bouveret's syndrome and clearly showed a large (diameter,
5.8 cm) laminated gallstone located in the duodenal bulb and causing partial
gastric outlet obstruction (Fig.
1C). In the 2 months between the upper gastrointestinal studies,
the gallstone had migrated from the gallbladder lumen to the duodenal bulb
lumen. Enhanced CT of the abdomen using IV and oral contrast material
(5-mm-thick axial sections) showed air in the gallbladder lumen, gallbladder
wall thickening, and oral contrast agent surrounding the gallstone
(Fig. 1D). The oral contrast
medium surrounding the gallstone indicated the location of the stone within
the duodenal bulb.
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Fig. 1C. —79-year-old woman with Bouveret's syndrome. Upper
gastrointestinal radiograph obtained 2 months after initial study (A)
shows laminated stone (arrow) surrounded by contrast agent
(arrowheads) in duodenal bulb, producing partial gastric outlet
obstruction.
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Fig. 1D. —79-year-old woman with Bouveret's syndrome. Enhanced CT scan
obtained 2 months after initial study (A) shows large gallstone located
in duodenal bulb, surrounded by contrast agent (arrows). Note
pneumobilia from biliary-enteric fistula and thickening of gallbladder
wall.
|
|
The patient was taken to the operating room, and at surgery the gallbladder
was found to be firmly adherent to the duodenal bulb, with a large gallstone
lodged in the duodenal bulb. The large stone could be removed only by breaking
it piecemeal into smaller fragments with a Kocher forceps introduced through a
pyloroplasty incision. The cholecystoduodenal fistula was repaired, and
cholecystectomy was not performed during the surgery.
The patient had an uneventful postoperative course and was discharged.
Discussion
Bouveret's syndrome is a type of gallstone ileus in which the stone is
lodged in the duodenum or the stomach. In 85% of patients with biliary-enteric
fistula, the fistula communicates with the duodenum and the stones will pass
spontaneously without causing bowel obstruction, whereas in 15% of patients,
the clinical features of bowel obstruction develop. In descending order of
frequency, the gallstone can be lodged in the terminal ileum, proximal ileum,
distal jejunum, colon, and duodenum or stomach. Diagnosing Bouveret's syndrome
is important because the literature has reported its surgical mortality rate
to be as high as 30% [9].
In patients with Bouveret's syndrome caused by a calcified gallstone,
radiography will show pneumobilia with the gallstone in the region of the
duodenum or stomach. Comparison with an earlier radiograph may show a relative
change in the position of the gallstone thus suggesting the location of the
stone outside the gallbladder. Upper gastrointestinal radiography can show a
filling defect in the duodenum that produces partial or complete gastric
outlet obstruction. In the initial study of this patient, serial upper
gastrointestinal radiography showed the irregular gallstone impression; 2
months later, it showed the gallstone located within the duodenal bulb.
In this patient, the initial CT showed air in the gallbladder and the
gallstone abutting the duodenal bulb. The CT performed 2 months later showed
oral contrast medium surrounding the gallstone and air in the gallbladder. Air
in the gallbladder on the initial CT scan indicates that erosion of the
duodenal wall by the gallstone had occurred at the time but that it had not
been visible at endoscopy because of the pyloric stenosis encountered by the
gastroenterologist.
In the past, Bouveret's syndrome was most often diagnosed on the basis of
endoscopy and upper gastrointestinal radiography. Now CT, which is
increasingly used in emergency departments for abdominal pain, will reveal
this unusual condition more frequently. Radiologists should become familiar
with the imaging appearance of this condition, which causes significant
morbidity and mortality.
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Introduction
Case Report
