Bouveret Syndrome - Symptoms, Diagnosis, and Treatment

Introduction:

The gallbladder is an essential organ in our system that stores bile (digestive juice) and releases it to the small bowel to aid in fat digestion. The store bile may get hardened to form stones in a few instances. These stones may clear up gradually, but the larger ones cause severe complications. One such complication is Bouveret syndrome. Read below to know more.

What Is Bouveret Syndrome?

Bouveret syndrome denotes a gastric outlet blockage that occurs due to the impaction of a large gallbladder stone in the stomach or small bowel. Due to various reasons, a large stone may form in the gallbladder, which may enter the small bowel or stomach through an abnormal passage (fistula). It leads to obstruction of the gastric outlet.

Is Bouveret Syndrome Common?

M. Beassier, a French Surgeon, first reported the disorder in 1770. Later, a French physician named L. Bouveret published two reports on this condition in 1896. However, reports show that only 315 cases were noted between 1967 to 2016. It indicates the rare nature of Bouveret syndrome. In addition, it accounts for 1 to 3 % of all gallstone obstructions.

What Are the Risk Factors for Bouveret Syndrome?

Bouveret syndrome is considered to be a severe complication of a gallbladder stone (cholelithiasis).

However, the following factors increase the risk of it:

• Female gender.

• Advanced age (above 60 years).

• History of cholelithiasis, jaundice, and gallstone in the bile duct.

• Gallstones larger than 2 cm to 8 cm.

What Are the Signs and Symptoms?

The intensity of the symptoms keeps fluctuating, and it includes:

• Nausea.

• Vomiting.

• Abdominal swelling.

• Pain mainly in the right upper portion of the abdomen.

• Weight loss.

• Dehydration.

• Vomiting blood may happen less frequently.

How Is Bouveret Syndrome Diagnosed?

1) Physical Examination - The physician may look for abdominal swelling, pain, dry mucous membranes, and other signs of jaundice. But, these findings do not confirm the diagnosis, and the following investigations are necessary.

2) Plain Radiograph - The abdominal radiographs are not so specific and accurate in diagnosing Bouveret syndrome. The other findings that are less noticed include:

• Bowel obstruction.

• Enlarged stomach.

• Abnormal location of gallstone.

• Accumulation of gas in the gallbladder and bowel.

3) Computed Tomography - A particular and accurate imaging technique in detecting Bouveret syndrome. It gives a detailed view of the following:

• Number and size of gallstones present.

• Fistula.

• Any abscess, if present.

• Surrounding tissues.

The classic triad of Bouveret syndrome, Rigler’s triad, is usually visualized in 40 to 50 % of cases. It consists of the following:

• Ectopic location of gallbladder.

• Bowel obstruction.

• Presence of gas within the bile ducts and bowel.

4) Magnetic Resonance Cholangiopancreatography (MRCP) is a type of magnetic resonance imaging (MRI) that does not require a contrast agent like the typical MRI. It is highly efficient in differentiating stones from other fluids and provides a detailed image of the fistula.

5) Esophagogastroduodenoscopy (EGD) - The healthcare specialist may insert a flexible tube into the mouth, passing the food pipe to the stomach. It provides a detailed image of the stomach and small bowel. It also aids in treating other conditions of the upper gastrointestinal tract.

What Are the Similar Conditions?

• The inflammation of the digestive tract characterizes Crohn’s disease. It produces symptoms like fatigue, abdominal pain, fever, loss of weight, etc. Similar to Bouveret syndrome, the symptoms occur in episodes.

• Peptic ulcer disease causes ulcers on the stomach and small bowel lining. Stress, smoking, alcohol consumption, certain medications, and bacteria are responsible for causing peptic ulcers.

• Erosive gastritis refers to the inflammation of the stomach's mucosal lining that leads to the formation of sores on it. Severe ulcers require immediate treatment.

• The obstruction of the small bowel characterizes the duodenal web. The affected individual may have upper abdominal pain, vomiting, and abdominal swelling.

Can Bouveret Syndrome Be Treated?

1) Endoscopy - It is the most preferred treatment as it is minimally invasive. The first endoscopic technique for visualizing and removing gallstones was successful in 1985. But, endoscopy is productive in removing stones of smaller sizes. In addition, the prognosis of treatment is less compared to surgery.

2) Lithotripsy is a non-surgical method that involves crushing the stone and then removing them with nets, baskets, or other instruments.

• Electrohydraulic lithotripsy is also used to remove large stones, whereas high-intensity shock waves are used to break the storm into smaller particles and remove them. Stones larger than 2.5 cm are effectively removed by lithotripsy procedure. However, the main drawback is that bleeding and perforation may occur if shock waves are focused on the bowel wall during the procedure.

• Laser lithotripsy is considered safe in treating gallstones as it focuses the high energy on the stone, and the tissues are less damaged. It provides excellent access for the healthcare specialist to control the laser application. Holmium and Neodymium lasers are approved by the Food and Drug Administration (FDA) to be used in the laser lithotripsy technique.

3) Surgery - In the past decades, surgery was the primary procedure in treating Bouveret syndrome. However, it is not advisable in elderly patients and is considered only if the endoscopic procedure did not help the effective removal of gallstones.

• Cholecystectomy: If there is a high risk and complications associated with the gallstones, the doctor may suggest the surgical removal of the gallbladder. The fistula is also repaired, along with removing the gallbladder if required.

What Are the Complications of Bouveret Syndrome?

The severe obstruction of the gastric outlet leads to the following complications if left untreated:

• Dehydration (loss of body fluids).

• Anorexia.

• Electrolyte imbalance.

• Nutritional deficiency.

• Bowel perforation (development of a hole in the intestine wall).

Conclusion:

Bouveret syndrome is an infrequent complication of gallstones, and it requires high knowledge of the healthcare specialist in diagnosing such conditions. The obstruction of the gastric outlet is a critical feature in diagnosis. However, with the help of endoscopy, the doctor may confirm Bouveret syndrome. In addition, the use of endoscopy and lithotripsy in gallstone retrieval has shown high success rates. Surgery is also an alternate option if the other mentioned procedures have not worked.