PWE-148 Bouveret's syndrome: leaving no stone unturned

Introduction Bouveret9s syndrome is a clinically distinct form of gallstone ileus caused by the formation of a fistula between the biliary tract and duodenum. Early recognition and treatment can significantly improve morbidity and mortality. We present two cases that have been successfully treated at our hospital. Methods Patient A is 71-year-old lady who was referred for gastroscopy after a CT abdomen that was performed to investigate her weight loss showed deformity of the duodenal cap. The gastroscopy showed a large gallstone obstructing the pyloric opening (Abstract PWE-148 figure 1A). Endoscopic removal was unsuccessful. She then developed vomiting and abdominal pain. Blood tests showed raised inflammatory markers and liver function tests. Repeat gastroscopy showed that the gallstone had passed down the pylorus, revealing a fistula opening in the duodenum (Abstract PWE-148 figure 1B). Diagnosis was confirmed on repeat CT abdomen which showed pneumobilia and two large gallstones that had migrated to the ileum (Abstract PWE-148 figure 1C). Patient B is 87-year-old lady who presented with a 1-week history of vomiting and haematemesis. Her blood tests on admission showed raised inflammatory markers with normal liver function tests. Gastroscopy showed oesophagitis, a duodenal ulcer and obstructing gallstone. Gastrograffin studies then showed that the gallstone had migrated to the proximal jejunum (Abstract PWE-148 figure 1D) and this was confirmed on CT abdomen. Results Patient A was treated with a Ryle9s tube insertion for stomach decompression, intravenous fluids, antibiotics and peripheral parenteral nutrition. She underwent a laparotomy, which showed distended fluid filled small bowel, with a large 5×3 cm gallstone lodged in the ileum. An ileal enterotomy was performed and the gall stone excised. Patient B was treated with a Ryle9s tube insertion, intravenous fluids and peripheral parenteral nutrition. She underwent a laparotomy, in which a gallstone was found lodged in the proximal jejunum and surgically removed. Both patients made a full recovery and were discharged home. Conclusion Bouveret9s syndrome is rare and accounts for 1–3% of gallstone ileus. We have now encountered two cases in our hospital recently. This may reflect the rise in our ageing population, as a major risk factor for developing this syndrome is age >70 years. Establishing the diagnosis early requires an awareness of this syndrome and prompt recognition of the signs. Contrast enhanced CT is the investigation of choice. In addition to this, a combined care approach between the gastroenterologists, surgeons and nutrition team is crucial to a successful outcome, hence our wish to present these cases. Competing interests None declared. Reference 1. Cappell MS , Davis M. Characterization of Bouveret9s syndrome: a comprehensive review of 128 cases. Am J Gastroenterology 2006; 101 :2139–46.