Bouveret Syndrome: When There Are No Options

Abstract

Division of Gastroenterology, McMaster University, Hamilton, Ontario Corrrespondence: Dr Harith Baharith, McMaster University, Division of Gastroenterology, 1280 Main Street West, Hamilton, Ontario L8N 3Z5. Telephone [phone], fax [phone], e-mail [e-mail] Received for publication November 10, 2014. Accepted December 5, 2014 CASE PRESENTATION An 85-year-old female nursing home resident presented with a medical history of dementia, stroke, hypertension, gastroesophageal reflux disease and cholethiasis. The patient was referred because of four episodes of coffee-ground emesis and symptoms of right upper quadrant abdominal pain, with no issues with bowel movements. There was limited other information available due to the underlying history of dementia. The patient’s vital signs were stable. Physical examination revealed normal cardiorespiratory parameters. The abdominal examination revealed a tender right upper quadrant, with no palpable mass and the presence of bowel sounds. Laboratory investigations revealed a white blood cell count of 18.4×109/L (normal 4.0×109/L to 11.0×109/L), alkaline phosphatase level of 131 U/L (normal 40 U/L to 120 U/L) and gamma-glutamyl transferase level of 116 U/L (normal <37 U/L). The remaining laboratory investigations were unremarkable. An abdominal x-ray revealed a large, rounded, lamellated calcification in the epigastric region measuring approximately 4.5 cm × 3.3 cm (Figure 1). The patient underwent a computed tomography scan, which revealed gastric outlet obstruction secondary to an impacted gallstone within the duodenum, a cholecystoduodenal fistula and a collpased gallbladder, with thickening of the gallbladder wall and air within the gallbladder (Figure 2). The patient was initially managed with intravenous fluids, nasogastric tube, antiemetics and antibiotics. An urgent endoscopy was arranged by gastroenterology, revealing a stone impacted in the duodenal cap (Figure 3). Attempts to push or bypass the stone were unsuccessful, followed by attempts at retrieval with snare, basket, pronged grasper and Roth net, all of which were also unsuccessful. Additional attempts by another gastroenterologist and surgeon using endoscopic therapy to disimpact the stone were unsuccessful. The surgeon then suggested operative management for the patient; however, due to the patient’s deteriorating medical condition, the palliative team involved in her care and the family elected to proceed with palliation instead of surgery. After a three-week hospital stay, the patient was transferred to a hospice care facility where she died within one week.