A 69-year-old man has repeatedly vomited blood for 1 week, but he was blocked by a stone?

Only for medical professionals to read for reference.
Have you ever seen such a special gallstone intestinal obstruction if a stone is stuck between the gallbladder and the duodenal bulb? Cholelithiasis is a common clinical disease.

Gallstone intestinal obstruction is one of the rare and important causes of mechanical intestinal obstruction.
The cause is the "open tunnel" (biliary gastric fistula or biliary intestine fistula) between the gallbladder and the gastrointestinal tract.
Plugging the small intestine cavity, this is actually a traffic congestion incident self-directed and performed by the blocking stone in the intestine.

However, for a case of gastrointestinal obstruction caused by gallstones reported by Sheung LM et al.
[1], the location of traffic obstruction caused by the road stone was not the common jejunum.

Let's take a look at what's going on.
A 69-year-old man who has repeatedly vomited blood for 1 week.
This is a 69-year-old man who has repeatedly vomited undigested stomach contents and coffee grounds and discharged tarry stool for 1 week.

The patient’s past medical history includes hypertension, dyslipidemia, and ischemic heart disease.
He is taking aspirin and is generally in good condition.

On admission, the patient had no fever and his vital signs were stable.

The physical examination showed a soft abdomen and no tenderness, but the upper abdomen was distended, and the vibrating sound was positive.

Digital rectal examination showed brown stool.

The blood test showed a slight increase in the white blood cell count (10.
5×109/L).

The chest radiograph showed no free air under the diaphragm, but the stomach was dilated, showing that the air was flat.

Gastroscopy revealed a large amount of bile-colored fluid in the dilated gastric cavity, distortion of the pylorus shape and thickening of the annular mucosa.

In the case of difficult operation, a gastroscope tube with a diameter of 5mm can only pass through the slit-like narrow pyloric opening.

The mucosa of the duodenal bulb was also thickened in an annular shape, the descending part was normal, and no stones were seen.

Pathology of multi-site biopsy of the pylorus showed only ulcers and no evidence of malignancy, and Helicobacter pylori was negative.

However, follow-up abdominal CT showed that there was a gallbladder-duodenal fistula between the gallbladder and the duodenal bulb.
There was a gallstone (circular calcification) with a diameter of about 2 cm, accompanied by local irregular increase of the pylorus and duodenal bulb.
Thick and diffuse thickening of the gallbladder wall (as shown in the picture below).

CT of the abdomen showed a gallbladder-duodenal fistula between the gallbladder and the duodenal bulb, which contained a gallstone with a diameter of about 2 cm and a circular calcification [1] The patient underwent emergency laparotomy.
A 2.
4cm calculus with dense scar tissue was found in the fistula between the bulbs, causing gastric outflow tract obstruction.

In addition, the Calot triangle, duodenal bulb, hepatic hilum, gallbladder and pancreatic head area had significant fibrosis and scar formation.

The patient's final diagnosis is Bouveret syndrome.

The patient underwent partial gastrectomy, cholecystectomy, and duodenostomy.

The whole specimen after partial gastrectomy and cholecystectomy (including gallbladder duodenal fistula) showed a 2.
4 cm stone and multiple small gallstones [1] After the operation, the patient's condition was stable, and the oral intake was gradually restored.
Well tolerated.

On the 9th day after the operation, the duodenography showed that the contrast agent could flow smoothly into the jejunum without leakage.
The patient was discharged on the 11th day after the operation.

Gallstone intestinal obstruction and Bouveret syndrome.
Gallstone intestinal obstruction is an important complication of cholelithiasis and a rare cause of mechanical intestinal obstruction.

However, due to the high prevalence of cholelithiasis, the possibility of gallstone intestinal obstruction should be considered when encountering patients with acute abdomen in clinical practice.

In patients with gallstone intestinal obstruction, the most common site of block stone impaction is ileum (50.
0%-60.
5%), jejunum (16.
1%-26.
9%), duodenum (3.
5%-14.
6%), colon (3.
0%) -4.
1%) [2].

Josè Vitale and others reported in The Lancet that a 71-year-old woman with a history of metastatic breast cancer, metabolic syndrome, and asymptomatic gallstones, presented to the doctor due to nausea and vomiting, constipation, and abdominal pain.
Enhanced CT of the abdomen finally confirmed biliary-enteric fistula , Distal ileum gallstones complicated by gallstone intestinal obstruction [3].

A 71-year-old female’s enhanced CT showed biliary-enteric fistula (arrow) and gallstones in the distal ileum.
[3] Bouveret syndrome is a special type of gallstone intestinal obstruction.
The cause is that gallstones pass through gallbladder gastric fistula and gallbladder twelve.
The fistula of the digital fistula is impacted in the pylorus or the proximal part of the duodenum and secondary gastric output tract obstruction.

Bouveret syndrome was first reported by French doctor Leon Bouveret in 1896, and its incidence was 1%-3%[1].

The difference from the common types of gallstone intestinal obstruction is that the road stone is incarcerated in the pylorus or proximal duodenum or even in the fistula.
Therefore, the location of the traffic obstruction is not in the jejunum and ileum, but the gastric outflow tract.

This is a gallstone intestinal obstruction that is not well understood by clinicians and easily overlooked.

Risk factors for Bouveret syndrome include history of cholelithiasis, stones over 2-8 cm in size, female, and elderly over 60 years of age.

The size of the gallstones involved in Bouveret syndrome is usually larger than 2.
5cm, because stones smaller than this volume usually do not stay in the gastric outflow tract and cause obstruction [4].

The clinical manifestations of Bouveret syndrome The clinical manifestations of Bouveret syndrome lack specificity.
As gallstones can "tumbling" (Tumbling phenomenon) in different parts of the upper gastrointestinal tract, patients may experience "onset-relief-onset" intermittent symptoms .

The patient's symptoms usually start 5-7 days before seeking medical attention [4].

In a retrospective analysis of 128 patients with Bouveret syndrome, the average age of the patients was 74.
1±11.
1 years, and the male to female ratio was 1.
86:1.

The most common symptoms of patients include nausea and vomiting (87%, stones can be seen in the vomit of a few patients), abdominal pain (71%), hematemesis (15%, often secondary to duodenal erosion and abdominal dryness), weight loss (14%), loss of appetite (13%).

The common signs of Bouveret syndrome are abdominal tenderness (44%), dehydration (31%), and abdominal distension (26%) [5].

About 43%-68% of patients have a history of recurrent biliary colic, jaundice or acute cholecystitis [4].

Bouveret syndrome mostly involves patients who have multiple comorbidities.
Therefore, the disease often leads to multiple complications, including dehydration, malnutrition, electrolyte disturbance, and intestinal perforation.

Imaging examinations such as abdominal plain film, gastrointestinal angiography, abdominal ultrasound, abdominal CT, and endoscopy are important means of diagnosis.

Allen N et al.
also reported in the BMJ Case Rep magazine a case of an 80-year-old man with gastrointestinal obstruction and hiccups for 7 days.
Laboratory examination only revealed dehydration.

The abdominal plain film found that there was a high-density large stone in the right quarter rib area, and CT of the abdomen was further confirmed as a stone in the descending part of the duodenum with gastric outflow obstruction and pneumocystis [6].

Abdominal plain radiograph and abdominal CT of an 80-year-old man: high-density large stones in the descending part of the duodenum [6] Treatment and prognosis of Bouveret syndrome Because Bouveret syndrome is more common in the elderly and the elderly with multiple comorbidities, many in the past Scholars advocate the use of relatively less traumatic treatments such as endoscopy or laser or extracorporeal shock wave lithotripsy.

However, approximately 91% of patients require surgical treatment due to treatment failure [4].

The main reason why the endoscope is not effective is that the gallstone is large and the impaction site is located at the distal end of the duodenum [7].

Surgical methods include primary surgery (intestinal incision and lithotripsy to relieve intestinal obstruction, cholecystectomy, and biliary-enteric fistula repair), secondary surgery (intestinal incision and lithotripsy + cholecystectomy) and simple intestinal lithotripsy.

At present, there is still a lack of high-quality research evidence to support the best surgical procedure.

Laparoscopic surgery has a higher failure rate.

In recent years, although the mortality of Bouveret syndrome has decreased significantly, it is still as high as 12%-27%, and the risk of surgery-related mortality is low (5.
9%) [4,7].

Bouveret syndrome diagnosed and treated promptly has a good prognosis.

In summary, Bouveret syndrome is a rare type of gallstone intestinal obstruction, which is a traffic obstruction caused by a road stone after the tunnel (fistula) between the gallbladder and gastroduodenum is opened.

The clinical manifestations of Bouveret syndrome lack specificity and clinicians do not know enough about it.
Missed or misdiagnosed situations are not uncommon.
Bouveret syndrome still has a high mortality rate.

Therefore, for suspicious patients, imaging methods should be performed as soon as possible to confirm the diagnosis, in order to obtain early treatment and improve the prognosis.

Reference: [1]Sheung LM,Lam CT,Leung KW.
Bouveret's Syndrome:A rare cause of gastric outlet obstruction[J].
Surgical Practice,2019,23(2):68-71.
[2]Inukai K.
Gallstone ileus:a review.
BMJ Open Gastroenterol.
2019 Nov 24;6(1):e000344.
doi:10.
1136/bmjgast-2019-000344.
PMID:31875141;PMCID:PMC6904169.
[3]Vitale J,Boni L,Brumana N.
Biliary ileus.
Lancet.
2012 Jul 28;380(9839):366.
[4]Turner AR,Kudaravalli P,Ahmad H.
Bouveret Syndrome.
[Updated 2021 Feb 17].
In:StatPearls[Internet].
Treasure Island(FL) :StatPearls Publishing;2021 Jan-.
[5]Cappell MS,Davis M.
Characterization of Bouveret's syndrome:a comprehensive review of 128 cases.
Am J Gastroenterol.
2006 Sep;101(9):2139-46.
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[6]Allen N,Malik H,Pettit S.
Giant gallstone in the duodenum.
BMJ Case Rep.
2014 May 23;2014:bcr2014204938.
doi: 10.
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PMID:24859564;PMCID:PMC4039765.
[7]Ong J,Swift C,Stokell BG,Ong S,Lucarelli P,Shankar A,Rouhani FJ,Al-Naeeb Y.
Bouveret Syndrome:A Systematic Review of Endoscopic Therapy and a Novel Predictive Tool to Aid in Management.
J Clin Gastroenterol.
2020 Oct;54(9):758-768.
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PMID:32898384.