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A Massive Roadblock: An Unusual Case of Gastric Outlet Obstruction
July 8, 2020

A massive roadblock: An unusual case of gastric outlet obstruction

This CGH image case features a 76-year-old man who presented with 1 week of abdominal pain, nausea and bilious emesis.
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Check out this Electronic Image of the Month from the July 2020 issue of Clinical Gastroenterology and Hepatology (CGH)

A 76-year-old man presented with 1 week of abdominal pain, nausea and bilious emesis. Liver chemistry values were normal but his lipase level was increased to 394 U/L (reference range, 16–63 U/L). CT showed pneumobilia, common bile duct measuring 7 mm, decompressed gallbladder with a fistulous tract to the second portion of the duodenum, and a low-density laminated mass lesion in the third part of the duodenum with marked gastric and esophageal distention (Figure A).

Subsequent EGD showed a massive 8-cm impacted gallstone in the third portion of the duodenum with surrounding circumferential ulceration (Figure B). Despite extensive electrohydraulic lithotripsy, the stone was unable to be fragmented (Figure C). The patient underwent exploratory laparotomy and enterotomy with retrieval of a gallstone measuring 8 cm (Figure D).

Bouveret syndrome is an extremely rare form of gallstone ileus characterized by gastric outlet obstruction secondary to a large gallstone impacted within the duodenum or pylorus through a cholecystoduodenal or choledochoduodenal fistula. The incidence is 1% to 3%, with a surgical mortality rate approaching 15% to 33%. Prompt imaging is warranted and may show pneumobilia, bowel obstruction, and ectopic gallstone, also known as Rigler’s triad. Enterolithotomy, gastrostomy with cholecystectomy, and fistula repair are considered the mainstay of management but prompt gastroenterological evaluation is warranted.

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