Bouveret's syndrome complicated by a distal gallstone ileus

AIM:Gastric outlet obstruction caused by duodenalimpaction of a large gallstone migrated through acholecystoduodenal fistula has been referred as Bouveret’ssyndrome.Endoscopic lithotomy is the first-step treatment,however,surgery is indicated in case of failure or complicationduring this procedure.METHODS:We report herein an 84-year-old womanpresenting with features of gastric outlet obstruction dueto impacted gallstone.She underwent an endoscopicretrieval which was unsuccessful and was furthercomplicated by distal gallstone ileus.Physical examinationwas irrelevant.RESULTS:Endoscopy revealed multiple erosions aroundthe cardia,a large stone in the second part of the duodenumcausing complete obstruction,and wide ulceration in theduodenal wall where the stone was impacted.Several attemptsof endoscopic extraction by using foreign body forceps failedand surgical intervention was mandatory.Preoperativeultrasound evidenced pneumobilia whilst computerizedtomography showed a large stone,5 cm×4 cm×3 cm,loggingat the proximal jejunum and another one,2.5 cm×2 cm×2 cm,in the duodenal bulb causing a closed-loop syndrome.Sheunderwent laparotomy and the jejunal stone was removedby enterotomy.Another stone reported as located in theduodenum preoperatively was found to be present in thegallbladder by intraoperative ultrasound.Therefore,cholecystoduodenal fistula was broken down,the stone wasretrieved and cholecystectomy with duodenal repair wascarried out.She was discharged after an uneventfulpostoperative course.CONCLUSION: As the simplest and the least morbid procedure, endoscopic stone retrieval should be attempted in the treatment of patients with Bouveret’s syndrome.When it fails, surgical lithotomy consisting of simple enterotomy may solve the problem. Although cholecystectomy and cholecystoduodenal fistula breakdown is unnecessary