Unusual clinical course, Challenging differential diagnosis, Unusual or unexpected effect of treatment
Kayla K. Brown, Kyle J. Cunningham, Adam Howell, John Edward Vance
College of Osteopathic Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Davie, FL, USA
Am J Case Rep 2021; 22:e929150
Available online: 2021-03-16
Abnormal communicating channels or fistulas between the gallbladder or common bile duct and the intestine are rare, but have potential to result in serious complications. Further complications can arise with migration of gallstones from the gallbladder to the intestines, causing distal obstruction in the ileum, intestinal hemorrhage, or intestinal perforation. High clinical suspicion is warranted for the diagnosis of Bouveret’s syndrome, with anticipation of surgery to prevent distal gallstone migration that would otherwise result in unfavorable patient outcomes.
CASE REPORT: A 51-year-old woman presented with biliary colic and a computed tomography scan showed that a gallstone measuring approximately 3 cm was lodged in the first portion of the duodenum. The patient was diagnosed with cholecystoduodenal fistula with Bouveret’s syndrome. Because of the acute presentation of symptoms, she underwent an exploratory laparotomy with disconnection of the cholecystoduodenal fistula, cholecystectomy with debridement of the duodenum, transduodenal gallstone removal, and primary duodenoplasty closure of D1.
CONCLUSIONS: As the present case illustrates, distal migration of a gallstone through a cholecystoduodenal fistula can occur rapidly and without obvious symptoms. It also can occur spontaneously and not just secondary to fragmentation by laser lithotripsy. To prevent morbidity and mortality, a high degree of clinical suspicion is warranted when diagnosing patients in whom a gallstone ileus is seen on imaging.
Keywords: Biliary Fistula, Gallstones, Ileus