S3319 Bouveret Syndrome: A Consequential Complication of Gallstone Disease

Introduction: Bouveret syndrome is diagnosed when a gallstone, via a bilioenteric fistula, becomes impacted in the gastric antrum or proximal duodenum, causing gastric outlet obstruction (GOO). This is a rare phenomenon, as gallstone disease has a prevalence of 10%-15% in the United States, with bilioenteric fistulas developing in 1%-2% of patients. The most common site of bilioenteric fistula formation is between the gallbladder and the duodenum, with the most common symptoms being abdominal pain, nausea, and diarrhea; with GOO only occurring in 1%-3% of cases. Despite being a rare diagnosis, Bouveret syndrome should be considered in the appropriate clinical setting, as management can be complex, requiring a multidisciplinary approach. Case Description/Methods: An 80-year-old man with medical history of coronary artery disease, congestive heart failure, atrial fibrillation on anticoagulation, and ulcerative colitis, presented to the emergency department after 2 syncopal events. He was hypotensive, prompting a trauma code, given his fall while on anticoagulation. Abdominal computed tomography revealed a 27 mm calculus in the duodenal lumen and a non-dependent gas bubble in the gallbladder lumen. He required a massive transfusion protocol and intubation. An esophagogastroduodenoscopy revealed a 20 mm cholecystoduodenal fistula in the first portion of the duodenum. Bleeding from a lesion in the body of the gallbladder was addressed with argon plasma coagulation and application of a hemostatic clip. Before coordination of transfer for hepatobiliary surgical evaluation, the patient developed gallstone ileus for which he underwent exploratory laparotomy. Given his critical condition and poor prognosis, the patient's family decided to pursue palliative care, and he later expired. Discussion: Bouveret syndrome is a rare complication of gallstone disease with serious clinical consequences. Delayed or misdiagnosis is common, as presenting symptoms are nonspecific. In this case, incidental findings from the trauma work up assisted in making an early diagnosis. Once diagnosed, multidisciplinary management requires considerations be made for endoscopy, surgery, and lithotripsy. Unfortunately, despite treatment, mortality ranges from 12%-30%, owing to an increased prevalence in frail and elderly patients. In closing, it is because of the vague presenting symptoms, the complex management, and the high mortality rates, that clinicians should be familiar with the pathophysiology and diagnosis and Bouveret syndrome.