Bouveret syndrome with a synchronous jejunal gallstone in an elderly patient with high cardiac risk: A case report

Abstract

BACKGROUND

Bouveret syndrome occurs when a gallstone passes through a cholecystoenteric fistula and becomes impacted at the gastric outlet. It accounts for 0.3%-0.5% of gallstone-related complications and has a mortality rate of about 12%, primarily because it occurs in older patients with multiple comorbidities. A second stone may pass through the same fistula and lodge farther along the bowel. If overlooked, this stone can alter the operative plan.

CASE SUMMARY

A 72-year-old woman with hypertension, previous cerebral infarction, paroxysmal atrial fibrillation, and an unruptured intracranial aneurysm presented with gastric-outlet obstruction. Computed tomography (CT) demonstrated Rigler’s triad and a synchronous jejunal stone; enteroscopy identified an impacted 5-cm duodenal gallstone. Surgery was delayed for 18 days by recurrent atrial fibrillation, cardiac treatment, cerebrovascular-risk assessment, ward transfers, and attempts to improve nutrition and inflammation, without fully restoring physiological reserve. Cholecystectomy, distal gastrectomy, duodenostomy, gastrojejunostomy, and jejunal enterolithotomy were performed. Postoperatively, purulent drainage and carbapenem-resistant Acinetobacter baumannii in abdominal drainage fluid indicated intra-abdominal infection; pulmonary infection was also possible. Non-contrast CT showed no definite anastomotic or biliary leak. Sepsis, shock, acute kidney injury, and multiple organ dysfunction followed. Active treatment was discontinued, and she was discharged in extremis on November 7, 2020; the exact time of death was not documented.

CONCLUSION

CT detects synchronous ectopic stones; in high-risk patients, postoperative sepsis and limited cardiac reserve may hinder recovery.

Keywords: Bouveret syndrome; Gallstone ileus; Cholecystoduodenal fistula; Synchronous ectopic gallstone; Perioperative cardiac risk; Case report

Core Tip: This case report highlights two findings in Bouveret syndrome. Computed tomography can confirm the diagnosis through Rigler’s triad and detect ectopic stones distal to the main obstruction, which altered the surgical plan in our patient. In elderly patients with elevated N-terminal pro-B-type natriuretic peptide and cardiac troponin at admission, survival depends on the tolerance of the heart and lungs to postoperative sepsis rather than on technical success. Despite 18 days of coordinated preparation by five specialist teams, the underlying heart disease could not prevent death.