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Case Report |
1 Department of Radiology, National Naval Medical Center, 8901 Wisconsin Ave.,
Bethesda, MD 20889-5600.
2 Department of Radiology, F. Edward Hébert School of Medicine, Uniformed
Services University of the Health Sciences, 4301 Jones Bridge Rd., Bethesda,
MD 20814.
3 Radiology Imaging Associates, Ste. 250, 3900 S. Wadsworth Blvd. Lakewood, CO
80235.
4 South Denver Gastroenterology, Ste. 420, 499 E. Hampden Ave., Englewood, CO
80110.
Received July 12, 2002;
accepted after revision September 17, 2002.
Address correspondence to P. J. Pickhardt.
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Abdominal radiographs obtained with the patient in upright and supine positions showed pneumobilia without evidence of small-bowel obstruction or abnormal calcifications. Right upper quadrant sonography failed to show the gallbladder prospectively because of overlying gas (presumed to represent bowel). Abdominal CT after oral and IV contrast administration showed extensive pneumobilia, including air in a partially contracted gallbladder that appeared to communicate with the duodenum (Figs. 1A and 1B). A somewhat ovoid, noncalcified low-attenuation mass or fluid collection, with surrounding linear enhancement, was seen adjacent to the cholecystoduodenal fistula (Fig. 1C). Although an impacted ectopic gallstone in the lumen of the duodenal bulb (with surrounding mucosal enhancement) was suspected rather than an abscess or intramural mass, MRCP was performed to confirm these findings. MRCP showed a large intraluminal duodenal filling defect, with surrounding fluid that communicated via a fistula with the gallbladder (Figs. 1D and 1E). The stark signal dropout of the intraluminal mass on these heavily T2-weighted images confirmed the diagnosis of an impacted gallstone in the duodenal bulb as the cause of gastric outlet obstruction (Bouveret's syndrome).
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Esophagogastroduodenoscopy was subsequently performed, which showed the tip of a large, dark calculus protruding through the pylorus into the gastric lumen (Fig. 1F). The stone was captured with a lithotriptor and pulled back (with some difficulty) through the pyloric channel and into the stomach. The stone measured 3.5 cm in longest dimension. Lithotripsy was performed, and the smaller stone fragments were retrieved. The patient tolerated the procedure without complication. A conservative, nonoperative approach for the gallbladder and cholecystoduodenal fistula was initially attempted because the patient was a suboptimal surgical candidate, because of critical aortic stenosis. However, she returned 2 weeks later with Escherichia coli sepsis. An open cholecystectomy and fistula repair were subsequently performed without further complication.
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In the late nineteenth century, Bouveret described two patients with gastric outlet obstruction from impacted duodenal gallstones [7]. This unusual subset of gallstone ileus accounts for only 1–3% of cases [5, 8]. Clinically, patients will typically present with signs and symptoms of gastric outlet obstruction, often associated with epigastric pain. A minority of patients will present with upper gastrointestinal hemorrhage from secondary duodenal ulceration or cystic artery erosion [5].
In the appropriate clinical setting, a diagnosis of Bouveret's syndrome may be suggested on abdominal radiography if both pneumobilia and a sufficiently large calcified gallstone are identified; however, these conditions would be met in only a small fraction of cases. Sonographic diagnosis is also possible but generally difficult because the gallbladder is usually collapsed, air-filled, or both. With nonvisualization of the gallbladder, the large impacted duodenal calculus could be confused with an orthotopic gallstone showing a wall-echo shadow complex unless the calculus is outlined by sufficient fluid in the antroduodenal lumen [9]. Fluoroscopic contrast examination can confirm diagnosis in suspected cases by directly revealing a large filling defect in the duodenal bulb.
CT likely represents the single best imaging technique for the diagnosis of Bouveret's syndrome [2, 3]. CT is more comprehensive because it effectively evaluates pneumobilia, the impacted ectopic gallstone, and the cholecystocolic fistula. One potential drawback of CT, as shown in our patient, is that 15–25% of gallstones appear as isoattenuating relative to bile or fluid. MRCP may be useful in such cases because it clearly delineates fluid from calculi, which appear as signal voids against the high-signal fluid. MRCP can also directly depict the cholecystoduodenal fistula if sufficient fluid is present.
In patients with typical gallstone ileus with small-bowel obstruction, surgery is indicated to relieve the obstruction; cholecystectomy and surgical correction of the fistula are usually performed at this time to prevent future complications [4]. In the case of Bouveret's syndrome, however, endoscopic removal is often possible using mechanical, electrohydraulic, or laser lithotripsy [8]. Because the affected patients are often elderly and poor surgical candidates, conservative treatment for the gallbladder and fistula has been advocated, with some reports of success [8]. Unfortunately, an open surgical procedure was ultimately necessary in our patient after conservative measures failed.
In summary, Bouveret's syndrome represents an unusual variant of gallstone ileus. If the diagnosis is suggested by the patient's clinical history, conventional radiographic findings, or both (e.g., symptoms of acute gastric outlet obstruction and pneumobilia), CT is the most appropriate imaging test for further evaluation because sonographic diagnosis is often difficult. As we saw with our patient, MRCP may be useful in select cases to confirm the diagnosis.
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