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Asian J Endosc Surg ISSN 1758-5902

L E T T E R TO T H E E D I TO R

Bouveret’s syndrome: A rare cause of abdominal pain in the elderly presentation (3). Usual clinical signs include nausea, vomiting, epigastric pain and abdominal distension. Less frequently, jaundice, gastrointestinal hemorrhage, pancreatitis and duodenal perforation can occur. Typical radiographic signs are present in 30%–50% of cases and include aerobilia, gastric distension and a gallstone in the duodenum. CT is diagnostic in about 60% of cases. Gastrointestinal endoscopy is considered the gold standard exam because it enables direct visualization and extraction of the stone. Notwithstanding the low success rate of endoscopic treatment, it remains the first-line therapeutic option. Stones larger than 2.5 cm are generally difficult to extract endoscopically, but there have been reports of 3-cm stones being extracted. If endoscopic treatment fails, surgical management is required. Endoscopic laser lithotripsy, extracorporeal shockwave lithotripsy and intracorporeal electrohydraulic lithotripsy have been reported as alternatives to surgery. However, multiple sessions are usually needed. and inadvertent focusing of the shockwaves onto the intestine wall may cause bleeding and perforation (3,4). Bouveret’s syndrome is a rare condition that should be considered in elderly patients who present with persistent vomiting, especially when a gallstone history is known. We would like to note that despite several attempts to use different lithotripsy techniques, there is insufficient evidence to strongly recommend any of them. As such, surgery remains necessary in the majority of cases.

Gallstone ileus is both a rare cause of intestinal obstruction and a rare complication of gallstone disease. Herein we describe a case involving duodenal obstruction by a gallstone, or Bouveret’s syndrome, as well as a brief review of this syndrome. An 89-year-old woman was admitted to our institution (Coimbra Hospital and University Centre, Coimbra, Portugal) with a 2-day history of vomiting and mild epigastric pain. On physical examination, the patient was afebrile and hemodynamically stable, with mild tenderness to palpation in the epigastric area. Blood workup showed impaired renal function (urea 24.9, normal range [NR] 7.9–20.9 mmol/L; creatinine 3.23 μmol/L, NR 0.5–1.0 μmol/L) and elevated inflammatory parameters (leucocyte 25000/μL, NR 4.0–10.0/μL; C-reactive protein 30.1 mg/dL, NR 0–0.5 mg/dL). Abdominal ultrasound showed cholelithiasis. Abdominal CT revealed a calcified mass in the duodenum and suggested a cholecystoduodenal fistula. Upper endoscopy was then performed and showed a large, impacted gallstone in the duodenum (Figure 1). Despite several attempts to capture the stone with different endoscopic devices, it remained. The patient underwent enterolithotomy and made an uneventful recovery. Bouveret’s syndrome, recently classified by Csendes as Mirizzi’s syndrome type Vb, is defined as a gastric outlet obstruction caused by duodenal impaction of a large stone that passes into the duodenal lumen through a cholecystoenteric fistula. The majority of this these gallstones pass spontaneously. When obstruction occurs, it happens commonly in the terminal ileum (biliary ileus) (90%) and occasionally in the duodenum (3%) (1,2). Bouveret’s syndrome tends to occur more often in women (65%), who have a median age of 74 years at

References

Figure 1 Helical CT scan (left) and endoscopic image (right) showing a large stone impacted in the duodenum.

1. Beltrán M. Mirizzi syndrome: History, current knowledge and proposal of a simplified classification. World J Gastroenterol 2012; 18: 4639–4650. 2. Joshi D, Vosough A, Raymond T et al. Bouveret’s syndrome as an unusual cause of gastric outlet obstruction: A case report. J Med Case Rep 2007; 1: 73. 3. Doycheva I, Limaye A, Suman A et al. Bouveret’s syndrome: Case report and review of the literature. Gastroenterol Res Pract 2009; 2009: 1–4. 4. Menéndez P, Gambi D, Villarejo P et al. Íleo biliar subsecuente a una fistula colecistoduodenal (síndrome de Bouveret). Rev Clin Esp 2008; 208: 321–322. (in Spanish).

Joana Carvalheiro, Sofia Mendes & Carlos Sofia Department of Gastroenterology, Coimbra Hospital and University Centre, Coimbra, Portugal

Asian J Endosc Surg 7 (2014) 93 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd

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Bouveret's syndrome: a rare cause of abdominal pain in the elderly.

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