Tracking the Bouveret’s syndrome with today’s computed tomography technique: a case description

Introduction

The Bouveret’s syndrome, first described by French physician Léon Bouveret in 1896, is a rather uncommon case of gastric outlet obstruction due to the impaction of gallstone in duodenum through a cholecystoduodenal fistula (1-3). This syndrome occurs mostly in elderly patients and has been found associated with significant morbidity and mortality. While the ultimate treatment requires a surgical procedure, the diagnosis and all related decision making rely mainly on image feedbacks, such as ultrasound, X-ray radiography, magnetic resonance imaging, and endoscopy (4-6). In comparison, computed tomography (CT) has the advantage of being able to provide a complete view of the involved regions in fully three-dimensional (3D) space, with accessibility and convenience nowadays even in the emergency setting.

The value of CT in diagnosis and characterization of the Bouveret’s syndrome has been pointed out in several reports more than a decade ago (7-12). However, CT technology has gone through enormous evolvement over the years. Radiologists may benefit from getting familiar with the manifestation of the syndrome on routine clinical images obtained by the latest CT apparatus and post-processing methods. In this report, we present a case that was captured by CT at three characteristic phases across the gallstone migration: leading up to the impaction, during the process of the formation of the passage, and after the creation of the obstruction.

Case presentation

An 85-year-old man presented with a 5-day history of abdominal distension and fecal incontinence, recalling no specific cause. When admitted to hospital, he reported a >10 years history of hypertension, a >8 years history of coronary artery disease, and having received placement of coronary stent in 2015 and pacemaker in 2017. Contrast enhanced abdominopelvic CT suggested incomplete small bowl obstruction, a gallstone measured 33×48 mm with chronic cholecystitis, thickening of the gallbladder wall, mild pneumobilia, and mild peritoneal effusion. Although the stone appeared to be pressing on the duodenum, no obvious penetration was noticed between the gallbladder and the duodenum, as shown in Figure 1A,1B. Of note is the patient’s motion during the scan, which resulted in slightly disturbing but easily distinguishable artefacts on the CT image. The CT examination also revealed cysts and stones in both kidneys, fecal stones in the distal ileum, and calcification in the abdominal aorta wall. The cause of abdominal distension was bowl obstruction in the lower abdomen. The patient was managed conservatively with enema, rehydration, and nutrition therapy. One week later, his physical signs returned to normal so he was discharged.

Figure 1 Serial abdominopelvic CT of an 85-year-old male patient, revealing the development of the Bouveret’s syndrome. (A) CPR of the CT images acquired at the first admission. (B) An enlarged view on (A) shows a gallstone abutting the duodenum. (C) CPR of CT images acquired at the second admission (2.5 months after the first). (D) An enlarged view on (C) shows the formation of the fistula through the gallbladder wall into the duodenum. (E) CPR of CT images acquired at the third admission (3 weeks after the second). (F) An enlarged view on (E) shows the obstruction in duodenum caused by the migrated gallstone. (G) The hyper-realistic rendering view of the CT images offers a vivid depiction of the gastric outlet obstruction, the cholecystoduodenal fistula, as well as the surrounding organs and anatomical structures within the abdomen. CT, computed tomography; CPR, curved planar reconstruction.

Two and a half months later, the patient was re-admitted to hospital for gastrointestinal hemorrhage and was suspected of peptic ulcer or intestinal ischemia. CT suggested acute onset of chronic cholecystitis, increased pneumobilia as compared to the previous examination, inflammatory wall thickening of the left and right hepatic ducts and the common bile duct, edema in the descending duodenum and the right hemicolon, and significantly increased peritoneal effusion. As revealed in Figure 1C,1D, a cholecystoduodenal fistula had been formed, through which intestinal gas had entered into the gallbladder and caused pneumobilia. The impacting gallstone was the cause of gastrointestinal bleeding, which was aggravated by the patient’s long history of oral administration of Aspirin since the cardiac stent surgery. Considering the patient’s physical condition at the time, gastrointestinal endoscopy was not recommended. By applying vasoconstrictors, acid inhibitors, and rehydration, his stool returned to normal and he was discharged afterwards.

Three weeks later, the patient presented again with abdominal pain and was admitted for the third time. As shown by CT in Figure 1E-1G, the gallstone had migrated into the duodenum through the cholecystoduodenal fistula, got stuck in the transverse duodenum, and resulted in gastric outlet obstruction. The diagnosis was Bouveret’s syndrome. It was decided for the patient to receive cholecystectomy. Given the severity of the inflammation from the duodenum up to the gastric antrum, Billroth II gastrectomy was taken to avoid re-fistulation while allowing for effective recovery of gastrointestinal functions. The surgery was successfully carried out in the following week.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for publication of this article and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

The diagnosis of the patient’s first admission was bowl obstruction in the lower abdomen, which was revealed on CT images as well. Although the gallstone was detected also, it was not the direct cause of the bowl obstruction. With conservative management, the patient’s physical condition was stabilized. Given his age and his long history of cardiovascular diseases that are considerable risk factors for endoscopy, it was then decided, upon agreement with his accompanying relative, not to move on to retrieving the stone. At the time of the patient’s third admission, the challenge of endoscopic surgery had become prohibitively high, due to severe adhesion of the gallbladder and the duodenum, as well as the intense inflammation and the relatively long course of disease.

In most previous reports involving CT findings of the Bouveret’s syndrome, case images were provided only in axial views and only at the phase when the obstruction had already taken place, with a window setting focusing on the appearance of the stone but leaving rather little information for the rest of the region (3-12). The report of Singh et al. was an exception, where CT images before and after the obstruction, acquired two months apart, were presented to illustrate the development of the syndrome (11). Still, the illustration was limited to the axial perspective and the window setting seemed to have obscured plenty of remaining details of the abdomen. Two examples of CT curved planer reconstruction (CPR) images with a window setting close to routine abdominal CT that radiologists are familiar with today are available in Nickel et al. (12). Like many others, unfortunately, the observation with CPR was only hinted at the last diagnostic phase.

Compared to all relatively old reports, a serial CT manifestation across three characteristic phases is made available in this report, employing the most convenient and informative display setting. In particular, the so-called hyper-realistic rendering technique has been adopted for the first time to depict the Bouveret’s syndrome, which uses a concept similar to volume rendering (VR) but a far more advanced coloring and lighting system in order to give a pseudo-3D effect and mimic the natural perception of human eyes.

The case we present here not only fills the blank in documented image evidence of the Bouveret’s syndrome, for its rarity and interesting path of development, but also renews our expectation on the CT imaging technique nowadays when it comes to unusual cases as such.

Acknowledgments

Funding: This work was supported by the Chongqing Science and Health Joint Medical Research Project (No. 2024MSXM112).

Footnote

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://qims.amegroups.com/article/view/10.21037/qims-24-1242/coif). G.Z. is a current employee of United Imaging Healthcare. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for publication of this article and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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