in 1896 , bouveret reported gastric outlet obstruction due to gallstones with biliary - enteric fistula . since then , approximately 300 cases of this proximal gallstone ileus have been described worldwide .
patients with bouveret 's syndrome present with persistent vomiting , colicky epigastric pain , and dehydration .
the difficult and unpredictable nature of the pathological process may result in late diagnosis and treatment . as a matter of fact , in most of the reported cases ,
we report an unusual clinical presentation of bouveret 's syndrome with mild acute pancreatitis that was treated laparoscopically . to our knowledge
cause , clinical presentation , methods of diagnosis , and options for management of bouveret 's syndrome are also discussed .
a 76-year - old female presented with a 3-day history of persistent nausea , vomiting , and upper abdominal pain .
laboratory findings showed leukocytosis ( white blood cell count > 18,000 ) , increased c - reactive protein ( crp158 ) , increased serum amylasis ( 860 ui / l ) , lypasis ( 460 ui / l ) , and urea ( 80 mmol / l ) .
the plain abdominal x - ray appeared normal . the patient was resuscitated and admitted with a diagnosis of acute pancreatitis .
she remained stable over the next 48 hours but did not show any signs of clinical or biochemical improvement .
she underwent a ultrasound of her abdomen , which showed intrahepatic pneumobilia in the absence of stones or biliary tract dilatation .
an abdominal computed tomographic scan with intravenous contrast confirmed intrahepatic pneumobilia and showed 2 large stones of 3 cm and 5 cm in the duodenum .
esophagogastroduodenoscopy ( egds ) confirmed the presence of 2 stones , and no attempts to dislodge the stones were made .
calot 's triangle was dissected , and a fistula between hartmann 's pouch , the cystic duct at its junction with the common bile duct ( cbd ) , and the second portion of duodenum was visible .
the duodenum was dissected free , and the duodenal opening of the fistula was enlarged , the wedges excised , and 2 large stones extracted ( figure 1 ) .
the anterior aspect of the cbd was involved in the fistula and was repaired with interrupted suture on a t - tube .
a 20 f drain was left in the infrahepatic space . the gallbladder and the stones were retrieved separately by using 2 endo - bags . the umbilical incision was enlarged to extract the stones .
the postoperative period was uneventful ; the patient improved steadily and was discharged on postoperative day 8 .
two weeks later , the t - tube was removed after a negative contrast study .
gallstone ileus is due to a fistula between the gallbladder or the bile duct and the intestine .
the most common type of fistula is cholecystoduodenal ( 60% ) , followed by cholecystocolic ( 17% ) , cholecystogastric ( 5% ) , and choledochoduodenal ( 5% ) .
the destiny of the eroding stone(s ) is variable depending on its size , the intestinal segment involved , and the presence of concomitant intestinal stenosis .
it may be passed asymptomatically per rectum , may be vomited , or rarely , may cause intestinal obstruction that requires surgery ( 6% of cases ) .
the obstruction usually occurs in the distal ileum ( 50% to 75% ) , occasionally in the proximal ileum or jejunum ( 20% to 40% ) , and less frequently in the colon .
seldom , large stones may impact in more proximal portions of the intestine ( duodenum or stomach ) , causing gastric outlet symptoms , resembling bouveret 's syndrome .
mortality for gallstone ileus is high , occurring in up to 50% of patients ( generally between 15% and 30% ) .
the frequent old age of patients , the delay in diagnosis and treatment , and certainly the presence of the biliary - enteric fistula are the factors responsible for the high morbidity and mortality of this clinical condition .
the clinical features of bouveret 's syndrome are not pathognomonic , and due to its rarity , the diagnosis and treatment represent a challenge for the surgeon .
abdominal pain , nausea , and vomiting are the symptoms more frequently reported and are variably associated with abdominal distension , constipation , and fever .
hematemesis is present in less than 10% of patients , while melena is very rare .
initial presentation with massive arterial bleeding from an eroded cystic artery has also been reported .
jaundice and abnormal liver function tests are present in about one third of patients , and previous biliary symptoms are present in up to two thirds of patients .
a plain abdominal x - ray may show a distended stomach , extraluminal air in the right upper quadrant , and calcified shadows ( rigler 's triad , less the 30% of the patients ) .
contrast studies of the upper gastrointestinal tract may identify both the course of the fistula and the level of the obstruction .
abdominal ultrasound may detect the presence of the stones in the duodenum , detect the fistula or the choledocholithiasis , or both .
however , as observed in our patient , a distended abdomen or an  air filled  stomach can make this test unreliable .
esophagogastroduodenoscopy ( egds ) allows visualization of the stones impacted in the duodenum and should always be performed to establish the diagnosis , especially if the gastric outlet obstruction is accompanied by ematemesis .
small stones can also be retrieved , but the procedure is often unsuccessful and may lead to further stone impaction , lacerations , and perforations .
an abdominal ct scan facilitates the diagnosis of bouveret 's syndrome when the diagnosis is not straightforward .
the stomach may be distended with deformation of the antrum or duodenum ; cholelythiasis , cholecystitis , and the presence of air in the biliary tree are usually witnessed . in our case ,
a ct scan was performed with a working diagnosis of pancreatitis , and 2 large stones were visible in the duodenum . the presence of the 2 impacted stones was confirmed with egds , defining the anatomy and excluding other pathologies .
less invasive procedures , such as endoscopic retrieval of the stones or extracorporeal shock wave lithotripsy with subsequent endoscopic extraction , have been proposed . however , in addition to potential complications previously described , endoscopic treatment does not correct the underling fistula and could not exclude the presence of additional stones distally .
complete treatment aims to relieve the obstruction , to close the fistula , and to prevent relapses .
controversies exist regarding the use of simple enterolithotomy versus enterolithotomy associated with cholecystectomy and correction of the internal fistula as a 1- or 2-stage procedure .
a 1-stage procedure involving the removal of the gallbladder with fistula closure is associated with a mortality of 20% to 30% , while a simple enterolithotomy has a mortality of < 12% .
however , the enterolithotomy alone is associated with an increased incidence of biliary complications ( cholangitis , cholecystitis ) and with a recurrence rate of 4.7% . additionally , the risk of bleeding and gall - bladder carcinoma should be considered .
truncal vagotomy , antrectomy , gastric resection , or gastroenteric anastomosis have been described in association with cholecystectomy in the presence of large inflammatory masses . from the literature ,
it is clear that extended operation time alone does not affect the outcome , while delay in diagnosis and treatment do .
our patient had a delayed diagnosis due to the confusing pancreatic sufferance , but because of her good performance status , she was fit enough for 1-stage surgery .
we believe that whenever the physical conditions are satisfactory , extraction of the stone , closure of the fistula , and cholecystectomy should be performed to prevent further biliary complications .
no reports on laparoscopic treatment of bouveret 's syndrome , but our experience with this case , suggests the possibility of offering a trial of laparoscopic dissection .
both the fistula and the gallstones could be treated laparoscopically at the same time where the necessary expertise and equipment are available .
it remains clear that the surgeon should adapt the treatment strategy according to the patient 's age , general condition , and findings at surgery .
 gastric outlet obstruction as a result of gallstone ( bouveret 's syndrome ) is a rare but serious complication of cholelithiasis . 
 although patients present with persistent vomiting , colicky epigastric pain and dehydration , the clinical features of the bouveret 's syndrome are not pathognomonic . due to its rarity , the diagnosis and treatment represent a challenge for the surgeon . in most of the reported cases , 
 the diagnosis was made at the time of laparotomy . 
 we report an unusual clinical presentation of bouveret 's syndrome with mild acute pancreatitis that was treated laparoscopically . to our knowledge , this is the first described case . 
 cause , clinical presentation , methods of diagnosis , and options for management of bouveret 's syndrome are also discussed . 
INTRODUCTION
CASE REPORT
DISCUSSION