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<meta name="robots" content="INDEX,FOLLOW,NOARCHIVE" /><meta name="citation_inbook_title" content="StatPearls [Internet]" /><meta name="citation_title" content="Bouveret Syndrome (Bilioduodenal Fistula)" /><meta name="citation_publisher" content="StatPearls Publishing" /><meta name="citation_date" content="2023/03/13" /><meta name="citation_author" content="Anisha R. Turner" /><meta name="citation_author" content="Pujitha Kudaravalli" /><meta name="citation_author" content="Jasim H. Al-Musawi" /><meta name="citation_author" content="Hira Ahmad" /><meta name="citation_pmid" content="28613489" /><meta name="citation_fulltext_html_url" content="https://www.ncbi.nlm.nih.gov/books/NBK430738/" /><link rel="schema.DC" href="http://purl.org/DC/elements/1.0/" /><meta name="DC.Title" content="Bouveret Syndrome (Bilioduodenal Fistula)" /><meta name="DC.Type" content="Text" /><meta name="DC.Publisher" content="StatPearls Publishing" /><meta name="DC.Contributor" content="Anisha R. Turner" /><meta name="DC.Contributor" content="Pujitha Kudaravalli" /><meta name="DC.Contributor" content="Jasim H. Al-Musawi" /><meta name="DC.Contributor" content="Hira Ahmad" /><meta name="DC.Date" content="2023/03/13" /><meta name="DC.Identifier" content="https://www.ncbi.nlm.nih.gov/books/NBK430738/" /><meta name="description" content="Bouveret syndrome is a rare complication of gallstone disease (0.3% to 0.5%), characterized by gastric outlet obstruction (GOO).[1] This infrequent form of gallstone ileus arises from the impaction of a large stone in the proximal duodenum or pylorus secondary to a spontaneous fistula between the gallbladder and the duodenum or stomach (see Image. Gallstone Ileus in the Jejunum). Due to its rare nature, only 315 cases have been reported in 50 years between 1967 and 2016.[2] It was first described preoperatively by French surgeon M. Beassier in 1770. However, subsequently, L. Bouveret, a French physician, published 2 comprehensive case reports 1896 of this condition, and it was named after him.[3] Bouveret syndrome has a high mortality, estimated at 12 to 30%, because an elderly age group is usually afflicted, and delay of diagnosis owing to its non-specific presentation and the complexity of the disease.[4] Also, because the disease is rare, there is no agreed guidance for diagnostic workup and management, including endoscopic, laparoscopic, and open surgery." /><meta name="og:title" content="Bouveret Syndrome (Bilioduodenal Fistula)" /><meta name="og:type" content="book" /><meta name="og:description" content="Bouveret syndrome is a rare complication of gallstone disease (0.3% to 0.5%), characterized by gastric outlet obstruction (GOO).[1] This infrequent form of gallstone ileus arises from the impaction of a large stone in the proximal duodenum or pylorus secondary to a spontaneous fistula between the gallbladder and the duodenum or stomach (see Image. Gallstone Ileus in the Jejunum). Due to its rare nature, only 315 cases have been reported in 50 years between 1967 and 2016.[2] It was first described preoperatively by French surgeon M. Beassier in 1770. However, subsequently, L. Bouveret, a French physician, published 2 comprehensive case reports 1896 of this condition, and it was named after him.[3] Bouveret syndrome has a high mortality, estimated at 12 to 30%, because an elderly age group is usually afflicted, and delay of diagnosis owing to its non-specific presentation and the complexity of the disease.[4] Also, because the disease is rare, there is no agreed guidance for diagnostic workup and management, including endoscopic, laparoscopic, and open surgery." /><meta name="og:url" content="https://www.ncbi.nlm.nih.gov/books/NBK430738/" /><meta name="og:site_name" content="NCBI Bookshelf" /><meta name="og:image" content="https://www.ncbi.nlm.nih.gov/corehtml/pmc/pmcgifs/bookshelf/thumbs/th-statpearls-lrg.png" /><meta name="twitter:card" content="summary" /><meta name="twitter:site" content="@ncbibooks" /><meta name="bk-non-canon-loc" content="/books/n/statpearls/article-34490/" /><link rel="canonical" href="https://www.ncbi.nlm.nih.gov/books/NBK430738/" /><link rel="stylesheet" href="/corehtml/pmc/css/figpopup.css" type="text/css" media="screen" /><link rel="stylesheet" href="/corehtml/pmc/css/bookshelf/2.26/css/books.min.css" type="text/css" /><link rel="stylesheet" href="/corehtml/pmc/css/bookshelf/2.26/css/books_print.min.css" type="text/css" /><style type="text/css">p a.figpopup{display:inline !important} .bk_tt {font-family: monospace} .first-line-outdent .bk_ref {display: inline} </style><script type="text/javascript" src="/corehtml/pmc/js/jquery.hoverIntent.min.js"> </script><script type="text/javascript" src="/corehtml/pmc/js/common.min.js?_=3.18"> </script><script type="text/javascript">window.name="mainwindow";</script><script type="text/javascript" src="/corehtml/pmc/ncbimedia/ncbimedia.js"> </script><script type="text/javascript">var ncbimedia_baseDir = "/corehtml/pmc/ncbimedia/";</script><script type="text/javascript" src="/corehtml/pmc/ncbimedia/pmcmedia.js"> </script><script type="text/javascript" src="/corehtml/pmc/js/bookshelf/2.26/book-toc.min.js"> </script><script type="text/javascript" src="/corehtml/pmc/js/bookshelf/2.26/books.min.js"> </script>
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<div class="pre-content"><div><div class="bk_prnt"><p class="small">NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.</p><p>StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. </p></div></div></div>
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<div class="main-content lit-style" itemscope="itemscope" itemtype="http://schema.org/CreativeWork"><div class="meta-content fm-sec"><h1 id="_NBK430738_"><span class="title" itemprop="name">Bouveret Syndrome (Bilioduodenal Fistula)</span></h1><p class="contrib-group"><h4>Authors</h4><span itemprop="author">Anisha R. Turner</span><sup>1</sup>; <span itemprop="author">Pujitha Kudaravalli</span>; <span itemprop="author">Jasim H. Al-Musawi</span><sup>2</sup>; <span itemprop="author">Hira Ahmad</span><sup>3</sup>.</p><h4>Affiliations</h4><div class="affiliation"><sup>1</sup> Louisiana State University Shreveport</div><div class="affiliation"><sup>2</sup> Imperial College School of Medicine</div><div class="affiliation"><sup>3</sup> Nationwide Children's Hospital</div><p class="small">Last Update: <span itemprop="dateModified">March 13, 2023</span>.</p></div><div class="body-content whole_rhythm" itemprop="text"><div id="article-34490.s1"><h2 id="_article-34490_s1_">Continuing Education Activity</h2><p>Bouveret syndrome is caused by a large stone passing through a bilioduodenal fistula, causing gastric outlet obstruction. In recent years, morbidity and mortality rates have decreased but remain high, estimated at 60% and 12% to 30%, respectively. Unfortunately, the chance of misdiagnosis is still high due to non-specific symptoms and laboratory findings. This activity reviews the evaluation and management of Bouveret syndrome and highlights the role of interprofessional team members in collaborating to provide well-coordinated care and enhance patient outcomes.</p><p>
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<b>Objectives:</b>
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<ul><li class="half_rhythm"><div>Identify the etiology of Bouveret syndrome.</div></li><li class="half_rhythm"><div>Determine the process for assessing a patient suspected of having Bouveret syndrome.</div></li><li class="half_rhythm"><div>Differentiate the management options available for patients with Bouveret syndrome.</div></li><li class="half_rhythm"><div>Describe interprofessional team strategies to enhance care coordination and in turn, improve recognition and treatment of Bouveret syndrome.</div></li></ul>
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</p></div><div id="article-34490.s2"><h2 id="_article-34490_s2_">Introduction</h2><p>Bouveret syndrome is a rare complication of gallstone disease (0.3% to 0.5%), characterized by gastric outlet obstruction (GOO).<a class="bk_pop" href="#article-34490.r1">[1]</a> This infrequent form of gallstone ileus arises from the impaction of a large stone in the proximal duodenum or pylorus secondary to a spontaneous fistula between the gallbladder and the duodenum or stomach (see <b>Image.</b> Gallstone Ileus in the Jejunum). Due to its rare nature, only 315 cases have been reported in 50 years between 1967 and 2016.<a class="bk_pop" href="#article-34490.r2">[2]</a> It was first described preoperatively by French surgeon M. Beassier in 1770. However, subsequently, L. Bouveret, a French physician, published 2 comprehensive case reports 1896 of this condition, and it was named after him.<a class="bk_pop" href="#article-34490.r3">[3]</a> Bouveret syndrome has a high mortality, estimated at 12 to 30%, because an elderly age group is usually afflicted, and delay of diagnosis owing to its non-specific presentation and the complexity of the disease.<a class="bk_pop" href="#article-34490.r4">[4]</a> Also, because the disease is rare, there is no agreed guidance for diagnostic workup and management, including endoscopic, laparoscopic, and open surgery.</p></div><div id="article-34490.s3"><h2 id="_article-34490_s3_">Etiology</h2><p>Bouveret syndrome is the most infrequent variant of gallstone ileus. It results from a gallstone migrating through a bilioenteric fistula, obstructing the gastric outlet and occasionally in other portions of the intestine. The entry point is typically a fistula between the gallbladder and a portion of the stomach or intestine.<a class="bk_pop" href="#article-34490.r5">[5]</a><a class="bk_pop" href="#article-34490.r6">[6]</a> The well-studied risk factors for Bouveret syndrome include a history of cholelithiasis, stones greater than 2 cm to 8 cm, female gender, and age older than 60 years. It has been reported that approximately 43% to 68% of patients have a history of recurrent biliary colic, jaundice, or acute cholecystitis.<a class="bk_pop" href="#article-34490.r7">[7]</a></p></div><div id="article-34490.s4"><h2 id="_article-34490_s4_">Epidemiology</h2><p>Bouveret syndrome is extremely rare and constitutes 1 to 3% of all obstructions caused by gallstones in the gastrointestinal tract, representing 0.3 to 5% of cholelithiasis complications.<a class="bk_pop" href="#article-34490.r8">[8]</a><a class="bk_pop" href="#article-34490.r4">[4]</a> However, most stones are relatively small and pass unnoticed or with terminal ileum impaction. The highest prevalence of Bouveret syndrome is among frail older women, with a median age of 74 years and a female-to-male ratio of 1.9.<a class="bk_pop" href="#article-34490.r9">[9]</a><a class="bk_pop" href="#article-34490.r10">[10]</a> Thus, it has disproportionately high rates of morbidity and mortality.</p></div><div id="article-34490.s5"><h2 id="_article-34490_s5_">Pathophysiology</h2><p>Following an attack of acute cholecystitis, the resulting inflammation and adhesion of the gallbladder to GI, together with mechanical pressure applied by gallstones on the gallbladder itself and bowel wall, may result in an ischemic tear of the apposed gallbladder and enteric wall, this mechanism potentiates a fistula between the gallbladder and bowel where the gallstone could pass.<a class="bk_pop" href="#article-34490.r11">[11]</a> Apart from acute cholecystitis, a few case reports have been published of the development of a cholecystoenteric fistula consequent to a gallbladder malignancy.<a class="bk_pop" href="#article-34490.r12">[12]</a><a class="bk_pop" href="#article-34490.r13">[13]</a><a class="bk_pop" href="#article-34490.r14">[14]</a></p><p>Bilioenteric fistulas usually present as cholecystoduodenal fistulas and contribute to 68% of the cases (see <b>Image.</b> Computed Tomography of the Abdomen, Cholecystoduodenal Fistula). S cholecystocolic or cholecystogastric fistulas are less common variants, accounting for 17% and 5% of the cases, respectively.<a class="bk_pop" href="#article-34490.r15">[15]</a> Cholecystogastric fistula is probably the rarest because of the thickness of the gastric wall.<a class="bk_pop" href="#article-34490.r16">[16]</a> However, most ectopic gallstones pass through defecation or vomiting, even with a bilioenteric fistula. Clinically, symptoms of GOO are likely to arise with larger stones in addition to other factors like pre-existing stenosis or post-surgical altered anatomy of the gastrointestinal tract.<a class="bk_pop" href="#article-34490.r15">[15]</a><a class="bk_pop" href="#article-34490.r17">[17]</a></p></div><div id="article-34490.s6"><h2 id="_article-34490_s6_">History and Physical</h2><p>The presentation of Bouveret syndrome is typically non-specific and often with waxing and waning symptoms of nausea and vomiting (present in 85% of patients), abdominal distension, and pain (present in 70% of patients) due to the varying locations of the gallstone. The patient may also exhibit epigastric and right hypochondrium pain and signs of dehydration and weight loss. Less frequently, Bouveret syndrome may present with hematemesis secondary to duodenal and celiac artery erosions or the expulsion of stones in the vomitus. Usually, the symptoms begin 5 to 7 days before patients seek medical consultation. Notably, the intensity of the pain often does not correlate with the underlying anatomic alteration. A physical exam is also non-specific, although one may appreciate dry mucous membranes, abdominal distension, tenderness, high-pitched bowel sounds, and obstructive jaundice.<a class="bk_pop" href="#article-34490.r18">[18]</a></p></div><div id="article-34490.s7"><h2 id="_article-34490_s7_">Evaluation</h2><p>Unfortunately, laboratory studies are typically non-specific. Labs may show jaundice and hepatic enzyme alterations, but this is only seen in about one-third of the patients with Bouveret syndrome. Leucocytosis, electrolyte abnormalities, acid-base alterations, and renal failure may also be present, but the grade depends on the comorbidity, the intensity of the inflammatory response, and the compensatory mechanisms of the individual. As far as imaging is concerned, the constellation of pneumobilia, bowel obstruction, and an aberrant gallstone referred to as the Rigler triad is highly suggestive of Bouveret syndrome but is only found in 40% to 50% of cases (see <b>Image.</b> Bouveret Syndrome With Rigler Triad). Ultrasound may be useful, showing possible cholecystitis, dilated stomach, pneumobilia, and ectopic location of gallstone, yet bowel gas makes it suboptimal. If the gallbladder is contracted, it may be difficult to detect the exact location of the stone (orthotopic or ectopic) using ultrasound.<a class="bk_pop" href="#article-34490.r19">[19]</a><a class="bk_pop" href="#article-34490.r20">[20]</a><a class="bk_pop" href="#article-34490.r21">[21]</a></p><p>Abdominal radiographs, though non-specific, may help identify Bouveret syndrome. The subtle cues include pneumobilia, intestinal obstruction, aberrantly located gallstone, air-fluid levels in the right upper quadrant due to air in the gallbladder, gastric distention, and a change in the location of a previously observed stone. However, abdominal radiographs are only diagnostic in 21% of Bouveret syndrome cases. Computed tomography is the imaging modality of choice, with an overall 93% sensitivity, 100% specificity, and 99% diagnostic accuracy. In addition to its higher accuracy than a plain radiograph or ultrasound, it can also provide important information about the presence of a fistula, the presence of an abscess, the inflammatory state of the surrounding lumen and tissue, the size of the gallstone, and the number of gallstones.</p><p>In patients unable to tolerate oral contrast or with intense emesis, as well as in cases with iso-attenuating stones, magnetic resonance cholangiopancreatography can be utilized, as it distinguishes stones from fluid, visualizes the fistula with good precision, and does not require the use of oral contrast material. Esophagogastroduodenoscopy is another option with diagnostic and therapeutic advantages. However, simultaneous removal of the stone is only successful in a minority of cases and can be associated with further complications. In about 20% to 40% of cases, the final diagnosis is established intra-operatively when a patient is undergoing laparotomy for small bowel obstruction of an unknown cause. This applies particularly to the 15% to 25% of gallstones that are iso-attenuating and not visible on computed tomography scans.<a class="bk_pop" href="#article-34490.r22">[22]</a><a class="bk_pop" href="#article-34490.r18">[18]</a></p></div><div id="article-34490.s8"><h2 id="_article-34490_s8_">Treatment / Management</h2><p>The chance of spontaneous resolution of Bouveret syndrome after conservative treatment is rare.<a class="bk_pop" href="#article-34490.r18">[18]</a> Also, a dislodged stone can cause distal obstruction. Endoscopic intervention is currently the first line of treatment for this syndrome. Many case reports of successful endoscopic management have been published in recent decades.<a class="bk_pop" href="#article-34490.r23">[23]</a> The first successful endoscopic visualization and extraction of gallstones from 3 cases was published in 1985.<a class="bk_pop" href="#article-34490.r24">[24]</a> Subsequently, endoscopic nets and lithotripsy modalities were developed for gallstone extraction. This minimally invasive approach enjoys lower mortality and morbidity rates of endoscopy vs surgery (1.6% vs 17.3%) for Bouveret syndrome.<a class="bk_pop" href="#article-34490.r23">[23]</a> However, it has a markedly reduced success rate compared to surgical intervention (43.0% vs 94.1%).<a class="bk_pop" href="#article-34490.r25">[25]</a></p><p>Decompression of the distended stomach by a nasogastric tube should be performed before therapeutic endoscopy to reduce the risk of aspiration. More endoscopy-based treatment options have become available with continued progress and refinement of endoscopic techniques over the last 2 decades. This improvement is reflected in rising success rates for treating Bouveret syndrome from 13.6% - 18.0% to 43.0%.<a class="bk_pop" href="#article-34490.r18">[18]</a><a class="bk_pop" href="#article-34490.r25">[25]</a><a class="bk_pop" href="#article-34490.r26">[26]</a> Minimally invasive treatment includes endoscopic retrieval, mechanical, electrohydraulic lithotripsy, laser, and extracorporeal shock waves. Extraction of impacted stones by Endoscopic graspers, nets, snares, or baskets can be tried. An esophageal overtube or latex rubber can be used to avoid esophageal injury during extraction. Endoscopic nets are reportedly more effective for treating smaller-sized stones than larger ones.<a class="bk_pop" href="#article-34490.r27">[27]</a> Stones of diameter exceeding 2.5 cm need lithotripsy fragmentation to enhance easy passage through the distal alimentary tract and safe removal.</p><p>Mechanical lithotripsy is a common method used, and fluoroscopy is a preferable adjunct to avoid the instrument wrongly entering the cholecystoenteric fistula. The other common method of lithotripsy is electrohydraulic lithotripsy (EHL). High EHL intensity may be needed because of the large gallstones commonly found in cases of Bouveret syndrome.<a class="bk_pop" href="#article-34490.r28">[28]</a> The other problem with EHL is that incidental focusing of the shock waves on the intestine wall may cause bleeding and perforation.<a class="bk_pop" href="#article-34490.r29">[29]</a> Other endoscopic methods are laser lithotripsy and extracorporeal shockwave lithotripsy (ESWL). See <b>Video.</b> Bouveret Syndrome Treatment With Endoscopic Laser Lithotripsy.</p><p>The former was used in the mid-1980s for bile duct stone treatment.<a class="bk_pop" href="#article-34490.r30">[30]</a><a class="bk_pop" href="#article-34490.r31">[31]</a> Laser lithotripsy has been reported to be effective and safe in treating complicated bile duct stones.<a class="bk_pop" href="#article-34490.r32">[32]</a><a class="bk_pop" href="#article-34490.r33">[33]</a> The benefit of using laser lithotripsy is the precise energy targeting the stone with minimal tissue injury. The direct visual control of the laser application makes the treatment technically easy and safe.<a class="bk_pop" href="#article-34490.r34">[34]</a><a class="bk_pop" href="#article-34490.r35">[35]</a><a class="bk_pop" href="#article-34490.r36">[36]</a> The Food and Drug Administration has approved holmium and neodymium yttrium aluminum garnet lasers as treatments, and they are available on the market.<a class="bk_pop" href="#article-34490.r37">[37]</a> ESWL has a higher failure rate and is limited by lacking endoscopic control. Utilization of intraoperative ultrasound during ESWL is advisable to tackle the gallstones, as the intraabdominal gases often impede plain XR.<a class="bk_pop" href="#article-34490.r23">[23]</a><a class="bk_pop" href="#article-34490.r38">[38]</a></p><p>Of all the successful endoscopic interventions published in recent decades, visualization of the gallstones was achieved in approximately two-thirds of cases.<a class="bk_pop" href="#article-34490.r23">[23]</a> Moreover, less than two-thirds can be removed successfully.<a class="bk_pop" href="#article-34490.r18">[18]</a> Endoscopic modality may require more than 1 session, and fragments of stones can cause postoperative gallstone ileus.<a class="bk_pop" href="#article-34490.r23">[23]</a> Therefore, removing these fragments at the end of the procedure is essential.<a class="bk_pop" href="#article-34490.r34">[34]</a> Even so, endoscopic modalities present convenient alternatives, especially when patients are unsuitable for surgery. Also, the success rate of these techniques continue to increase in the future as technology continues to progress.</p><p>Surgery was considered first-line treatment in the past and has demonstrated higher success rates than the minimally invasive modality —up to 90% for enteric or gastric lithotomy alone and up to 82% with simultaneous fistula repair and cholecystectomy.<a class="bk_pop" href="#article-34490.r18">[18]</a> However, surgery has remarkable morbidity and mortality, 37.5% and 11%, respectively.<a class="bk_pop" href="#article-34490.r39">[39]</a> As this disease is usually seen in elderly patients with significant comorbidities, surgery is not feasible for many of these patients. Surgical options may need to be considered to treat patients with Bouveret syndrome when an endoscopic attempt is unsuccessful or no technical expertise is available. The surgical approach consists of open gastrotomy, pylorotomy, or duodenotomy at or proximal to the site of obstruction. Gastrotomy can be used for stone removal if it is possible to manipulate an impacted duodenal gallstone into the stomach.<a class="bk_pop" href="#article-34490.r40">[40]</a> With a distal duodenal impacted stone or a migrated stone into the proximal part of the jejunum, an enterotomy distal to Trietz ligament may be used for stone removal. The distal part of the small intestine must be examined to ensure no other migrated large stones may result in postoperative ileus. Endoscopy may be used as an adjunct to help maneuver the stone into a more suitable location to perform enterotomy or gastrotomy if the gallstone is detected in a difficult area to access during open surgery in 1 or 2 sessions.<a class="bk_pop" href="#article-34490.r41">[41]</a><a class="bk_pop" href="#article-34490.r42">[42]</a></p><p>Open surgery for Bouveret syndrome has high morbidity and mortality. When laparoscopic equipment and expertise are available, laparoscopic enterolithotomy should be considered the preferred approach and has been reported as effective and safe in managing this condition in the failure or unavailability of endoscopic therapies.<a class="bk_pop" href="#article-34490.r43">[43]</a><a class="bk_pop" href="#article-34490.r44">[44]</a> However, higher rates of conversion are seen in these difficult cases.<a class="bk_pop" href="#article-34490.r45">[45]</a><a class="bk_pop" href="#article-34490.r46">[46]</a> As with an open approach, stones can be removed by a laparoscope through duodenotomy, pylorotomy, or gastrotomy. After removing impacted gallstones, the small intestine needs to be examined to ensure there are no retained stones.</p><p>Cholecystectomy and fistula repair in 1 or a multi-step approach to treat Bouveret syndrome is debatable. Most patients are poor surgical candidates as they are older and have multiple comorbidities. Cholecystectomy with fistula repair is generally not recommended as the benefits of cholecystectomy in these patients generally outweigh the risks of further operations or complications from gallstones. However, there is always a risk for recurrent gallstone ileus and gallstone pancreatitis if the fistula is not repaired.<a class="bk_pop" href="#article-34490.r47">[47]</a> It is recommended to perform cholecystectomy in younger patients as there may be an increased risk of gallbladder cancer with cholecystoenteric fistula. Also, cholecystectomy is recommended if malignancy cannot be excluded with diagnostic imaging before surgery.<a class="bk_pop" href="#article-34490.r48">[48]</a> Cholecystectomy warrants consideration in other special conditions, including the previous history of gallstone ileus, common bile duct stone, and gallstone pancreatitis.<a class="bk_pop" href="#article-34490.r49">[49]</a></p></div><div id="article-34490.s9"><h2 id="_article-34490_s9_">Differential Diagnosis</h2><p>
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<b>Congenital Cause</b>
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</p><ul><li class="half_rhythm"><div>Duodenal web</div></li></ul><p>
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<b>Inflammatory Causes</b>
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</p><ul><li class="half_rhythm"><div>Erosive gastritis</div></li><li class="half_rhythm"><div>Peptic ulcer disease</div></li><li class="half_rhythm"><div>Crohn disease</div></li></ul><p>
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<b>Malignant Causes</b>
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</p><ul><li class="half_rhythm"><div>Gastric antral carcinoma</div></li><li class="half_rhythm"><div>Duodenal carcinoma</div></li><li class="half_rhythm"><div>Pancreatic carcinoma</div></li><li class="half_rhythm"><div>Ampullary carcinoma</div></li><li class="half_rhythm"><div>Cholangiocarcinoma</div></li></ul></div><div id="article-34490.s10"><h2 id="_article-34490_s10_">Prognosis</h2><p>Bouveret syndrome generally carries a good prognosis provided timely diagnosis and management. </p></div><div id="article-34490.s11"><h2 id="_article-34490_s11_">Complications</h2><p>The complications of untreated Bouveret syndrome include ongoing GOO, resulting in anorexia, dehydration, nutritional deficiencies, and electrolyte abnormalities. The most feared complication is intestinal perforation, which can lead to major morbidities. Specific complications are related to the mode of treatment strategy employed. Incomplete lithotripsy may lead to recurrent gallstone ileus (see <b>Image.</b> Migrated Gallstone After Endoscopic Lithotripsy). Shock wave dispersion may lead to damage to surrounding structures. If a fistula is not excised, there is a risk of recurrent Bouveret syndrome, biliary sepsis, gallstone pancreatitis, and theoretical cancer risk. Surgery in itself carries the inherent risks of bleeding and infection. In addition, cholecystectomy may result in inadvertent injury to the biliary tree, especially in the presence of inflammation.<a class="bk_pop" href="#article-34490.r50">[50]</a></p></div><div id="article-34490.s12"><h2 id="_article-34490_s12_">Deterrence and Patient Education</h2><p>Patients with endoscopic or surgical removal of obstructing stones only without closure of the cholecystoduodenal fistula should be educated on the potential complications of patency of this fistula. These include recurrence of bowel obstruction due to migration of other stones, biliary sepsis, and acute pancreatitis. Therefore, these should seek the emergency department in case of experiencing severe abdominal pain and vomiting.</p></div><div id="article-34490.s13"><h2 id="_article-34490_s13_">Pearls and Other Issues</h2><p>Although a large gallstone is the cause of GOO, a history of prior gallstone disease is only present in a few patients. Nevertheless, the condition should be considered in the differential diagnosis of elderly patients who have a history of chronic cholecystitis and present with repeated episodes of hematemesis or vomiting.</p></div><div id="article-34490.s14"><h2 id="_article-34490_s14_">Enhancing Healthcare Team Outcomes </h2><p>Bouveret syndrome is a very rare cause of GOO. Both the diagnosis and management are complex, and the disorder carries high morbidity and mortality. These patients are best managed by an interprofessional team that includes an emergency department physician, a general surgeon, a radiologist, a gastroenterologist, and specialty nurses. The best method of managing these patients still has not been determined, but the patients need close monitoring in an intensive care unit setting. Wound infections, fistula formation, and multiorgan failure have all been reported. The nurse must ensure the patients have deep venous thrombosis prophylaxis, as many remain bedridden for a prolonged time.<a class="bk_pop" href="#article-34490.r51">[51]</a><a class="bk_pop" href="#article-34490.r52">[52]</a><a class="bk_pop" href="#article-34490.r53">[53]</a></p></div><div id="article-34490.s15"><h2 id="_article-34490_s15_">Review Questions</h2><ul><li class="half_rhythm"><div>
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<a href="https://www.statpearls.com/articlelibrary/commentarticle/34490/?utm_source=pubmed&utm_campaign=comments&utm_content=34490" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Comment on this article.</a>
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</div></li></ul></div><div class="floats-group" id="article-34490.s16"></div><div class="floats-group" id="article-34490.s17"></div><div class="floats-group" id="article-34490.s18"></div><div class="floats-group" id="article-34490.s19"></div><div class="floats-group" id="article-34490.s20"></div><div id="article-34490.s21"><h2 id="_article-34490_s21_">References</h2><dl class="temp-labeled-list"><dt>1.</dt><dd><div class="bk_ref" id="article-34490.r1">Abou-Saif A, Al-Kawas FH. Complications of gallstone disease: Mirizzi syndrome, cholecystocholedochal fistula, and gallstone ileus. <span><span class="ref-journal">Am J Gastroenterol. </span>2002 Feb;<span class="ref-vol">97</span>(2):249-54.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/11866258" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 11866258</span></a>]</div></dd><dt>2.</dt><dd><div class="bk_ref" id="article-34490.r2">Jin L, Naidu K. Bouveret syndrome-a rare form of gastric outlet obstruction. <span><span class="ref-journal">J Surg Case Rep. </span>2021 May;<span class="ref-vol">2021</span>(5):rjab183.</span> [<a href="/pmc/articles/PMC8132588/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC8132588</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/34040753" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 34040753</span></a>]</div></dd><dt>3.</dt><dd><div class="bk_ref" id="article-34490.r3">Lawther RE, Diamond T. Bouveret's syndrome: gallstone ileus causing gastric outlet obstruction. <span><span class="ref-journal">Ulster Med J. </span>2000 May;<span class="ref-vol">69</span>(1):69-70.</span> [<a href="/pmc/articles/PMC2449161/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC2449161</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/10881651" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 10881651</span></a>]</div></dd><dt>4.</dt><dd><div class="bk_ref" id="article-34490.r4">Haddad FG, Mansour W, Deeb L. Bouveret's Syndrome: Literature Review. <span><span class="ref-journal">Cureus. </span>2018 Mar 10;<span class="ref-vol">10</span>(3):e2299.</span> [<a href="/pmc/articles/PMC5945273/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC5945273</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/29755896" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 29755896</span></a>]</div></dd><dt>5.</dt><dd><div class="bk_ref" id="article-34490.r5">Yılmaz EM, Cartı EB, Kandemir A. 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Bouveret syndrome and its imaging diagnosis. <span><span class="ref-journal">Radiol Bras. </span>2018 Jul-Aug;<span class="ref-vol">51</span>(4):276-277.</span> [<a href="/pmc/articles/PMC6124580/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC6124580</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/30202139" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 30202139</span></a>]</div></dd><dt>7.</dt><dd><div class="bk_ref" id="article-34490.r7">Haddad FG, Mansour W, Mansour J, Deeb L. From Bouveret's Syndrome to Gallstone Ileus: The Journey of a Migrating Stone! <span><span class="ref-journal">Cureus. </span>2018 Mar 26;<span class="ref-vol">10</span>(3):e2370.</span> [<a href="/pmc/articles/PMC5969802/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC5969802</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/29805939" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 29805939</span></a>]</div></dd><dt>8.</dt><dd><div class="bk_ref" id="article-34490.r8">Baharith H, Khan K. Bouveret syndrome: when there are no options. <span><span class="ref-journal">Can J Gastroenterol Hepatol. </span>2015 Jan-Feb;<span class="ref-vol">29</span>(1):17-8.</span> [<a href="/pmc/articles/PMC4334063/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC4334063</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/25706571" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 25706571</span></a>]</div></dd><dt>9.</dt><dd><div class="bk_ref" id="article-34490.r9">Ayantunde AA, Agrawal A. Gallstone ileus: diagnosis and management. <span><span class="ref-journal">World J Surg. </span>2007 Jun;<span class="ref-vol">31</span>(6):1292-7.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/17436117" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 17436117</span></a>]</div></dd><dt>10.</dt><dd><div class="bk_ref" id="article-34490.r10">Warren DJ, Peck RJ, Majeed AW. Bouveret's Syndrome: a Case Report. <span><span class="ref-journal">J Radiol Case Rep. </span>2008;<span class="ref-vol">2</span>(4):14-7.</span> [<a href="/pmc/articles/PMC3303235/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC3303235</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/22470599" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 22470599</span></a>]</div></dd><dt>11.</dt><dd><div class="bk_ref" id="article-34490.r11">Langhorst J, Schumacher B, Deselaers T, Neuhaus H. Successful endoscopic therapy of a gastric outlet obstruction due to a gallstone with intracorporeal laser lithotripsy: a case of Bouveret's syndrome. <span><span class="ref-journal">Gastrointest Endosc. </span>2000 Feb;<span class="ref-vol">51</span>(2):209-13.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/10650271" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 10650271</span></a>]</div></dd><dt>12.</dt><dd><div class="bk_ref" id="article-34490.r12">Zissin R, Osadchy A, Klein E, Konikoff F. Consecutive instances of gallstone ileus due to obstruction first at the ileum and then at the duodenum complicating a gallbladder carcinoma: a case report. <span><span class="ref-journal">Emerg Radiol. </span>2006 Mar;<span class="ref-vol">12</span>(3):108-10.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/16362271" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 16362271</span></a>]</div></dd><dt>13.</dt><dd><div class="bk_ref" id="article-34490.r13">Shinoda M, Aiura K, Yamagishi Y, Masugi Y, Takano K, Maruyama S, Irino T, Takabayashi K, Hoshino Y, Nishiya S, Hibi T, Kawachi S, Tanabe M, Ueda M, Sakamoto M, Hibi T, Kitagawa Y. Bouveret's syndrome with a concomitant incidental T1 gallbladder cancer. <span><span class="ref-journal">Clin J Gastroenterol. </span>2010 Oct;<span class="ref-vol">3</span>(5):248-53.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/26190330" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 26190330</span></a>]</div></dd><dt>14.</dt><dd><div class="bk_ref" id="article-34490.r14">Sharma D, Jakhetia A, Agarwal L, Baruah D, Rohtagi A, Kumar A. 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Bouveret syndrome-the rarest variant of gallstone ileus: a case report and literature review. <span><span class="ref-journal">Case Rep Surg. </span>2013;<span class="ref-vol">2013</span>:839370.</span> [<a href="/pmc/articles/PMC3707284/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC3707284</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/23864977" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 23864977</span></a>]</div></dd><dt>16.</dt><dd><div class="bk_ref" id="article-34490.r16">Osman K, Maselli D, Kendi AT, Larson M. Bouveret's syndrome and cholecystogastric fistula: a case-report and review of the literature. <span><span class="ref-journal">Clin J Gastroenterol. </span>2020 Aug;<span class="ref-vol">13</span>(4):527-531.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/32232771" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 32232771</span></a>]</div></dd><dt>17.</dt><dd><div class="bk_ref" id="article-34490.r17">Iancu C, Bodea R, Al Hajjar N, Todea-Iancu D, Bălă O, Acalovschi I. Bouveret syndrome associated with acute gangrenous cholecystitis. <span><span class="ref-journal">J Gastrointestin Liver Dis. </span>2008 Mar;<span class="ref-vol">17</span>(1):87-90.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/18392252" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 18392252</span></a>]</div></dd><dt>18.</dt><dd><div class="bk_ref" id="article-34490.r18">Cappell MS, Davis M. Characterization of Bouveret's syndrome: a comprehensive review of 128 cases. <span><span class="ref-journal">Am J Gastroenterol. </span>2006 Sep;<span class="ref-vol">101</span>(9):2139-46.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/16817848" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 16817848</span></a>]</div></dd><dt>19.</dt><dd><div class="bk_ref" id="article-34490.r19">Alibegovic E, Kurtcehajic A, Hujdurovic A, Mujagic S, Alibegovic J, Kurtcehajic D. Bouveret Syndrome or Gallstone Ileus. <span><span class="ref-journal">Am J Med. </span>2018 Apr;<span class="ref-vol">131</span>(4):e175.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/29555049" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 29555049</span></a>]</div></dd><dt>20.</dt><dd><div class="bk_ref" id="article-34490.r20">Su HL, Tsai MJ. Bouveret syndrome. <span><span class="ref-journal">QJM. </span>2018 Jul 01;<span class="ref-vol">111</span>(7):489-490.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/29394400" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 29394400</span></a>]</div></dd><dt>21.</dt><dd><div class="bk_ref" id="article-34490.r21">Di Re AM, Punch G, Richardson AJ, Pleass H. Rare case of Bouveret syndrome. <span><span class="ref-journal">ANZ J Surg. </span>2019 May;<span class="ref-vol">89</span>(5):E198-E199.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/29027328" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 29027328</span></a>]</div></dd><dt>22.</dt><dd><div class="bk_ref" id="article-34490.r22">Yu YB, Song Y, Xu JB, Qi FZ. Bouveret's syndrome: A rare presentation of gastric outlet obstruction. <span><span class="ref-journal">Exp Ther Med. </span>2019 Mar;<span class="ref-vol">17</span>(3):1813-1816.</span> [<a href="/pmc/articles/PMC6364238/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC6364238</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/30783453" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 30783453</span></a>]</div></dd><dt>23.</dt><dd><div class="bk_ref" id="article-34490.r23">Dumonceau JM, Devière J. Novel treatment options for Bouveret's syndrome: a comprehensive review of 61 cases of successful endoscopic treatment. <span><span class="ref-journal">Expert Rev Gastroenterol Hepatol. </span>2016 Nov;<span class="ref-vol">10</span>(11):1245-1255.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/27677937" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 27677937</span></a>]</div></dd><dt>24.</dt><dd><div class="bk_ref" id="article-34490.r24">Iñíguez A, Butte JM, Zúñiga JM, Crovari F, Llanos O. [Bouveret syndrome: report of four cases]. <span><span class="ref-journal">Rev Med Chil. </span>2008 Feb;<span class="ref-vol">136</span>(2):163-8.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/18483669" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 18483669</span></a>]</div></dd><dt>25.</dt><dd><div class="bk_ref" id="article-34490.r25">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. <span><span class="ref-journal">J Clin Gastroenterol. </span>2020 Oct;<span class="ref-vol">54</span>(9):758-768.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/32898384" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 32898384</span></a>]</div></dd><dt>26.</dt><dd><div class="bk_ref" id="article-34490.r26">Lowe AS, Stephenson S, Kay CL, May J. Duodenal obstruction by gallstones (Bouveret's syndrome): a review of the literature. <span><span class="ref-journal">Endoscopy. </span>2005 Jan;<span class="ref-vol">37</span>(1):82-7.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/15657864" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 15657864</span></a>]</div></dd><dt>27.</dt><dd><div class="bk_ref" id="article-34490.r27">Jindal A, Philips CA, Jamwal K, Sarin SK. Use of a Roth Net Platinum Universal Retriever for the endoscopic management of a large symptomatic gallstone causing Bouveret's syndrome. <span><span class="ref-journal">Endoscopy. </span>2016 Sep;<span class="ref-vol">48</span>(S 01):E308.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/27669536" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 27669536</span></a>]</div></dd><dt>28.</dt><dd><div class="bk_ref" id="article-34490.r28">Kaushik N, Moser AJ, Slivka A, Chandrupatala S, Martin JA. Gastric outlet obstruction caused by gallstones: case report and review of the literature. <span><span class="ref-journal">Dig Dis Sci. </span>2005 Mar;<span class="ref-vol">50</span>(3):470-3.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/15810628" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 15810628</span></a>]</div></dd><dt>29.</dt><dd><div class="bk_ref" id="article-34490.r29">Binmoeller KF, Brückner M, Thonke F, Soehendra N. Treatment of difficult bile duct stones using mechanical, electrohydraulic and extracorporeal shock wave lithotripsy. <span><span class="ref-journal">Endoscopy. </span>1993 Mar;<span class="ref-vol">25</span>(3):201-6.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/8519238" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 8519238</span></a>]</div></dd><dt>30.</dt><dd><div class="bk_ref" id="article-34490.r30">Kozarek RA, Low DE, Ball TJ. Tunable dye laser lithotripsy: in vitro studies and in vivo treatment of choledocholithiasis. <span><span class="ref-journal">Gastrointest Endosc. </span>1988 Sep-Oct;<span class="ref-vol">34</span>(5):418-21.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/2903114" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 2903114</span></a>]</div></dd><dt>31.</dt><dd><div class="bk_ref" id="article-34490.r31">Cotton PB, Kozarek RA, Schapiro RH, Nishioka NS, Kelsey PB, Ball TJ, Putnam WS, Barkun A, Weinerth J. Endoscopic laser lithotripsy of large bile duct stones. <span><span class="ref-journal">Gastroenterology. </span>1990 Oct;<span class="ref-vol">99</span>(4):1128-33.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/1975549" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 1975549</span></a>]</div></dd><dt>32.</dt><dd><div class="bk_ref" id="article-34490.r32">Lv S, Fang Z, Wang A, Yang J, Zhang W. Choledochoscopic Holmium Laser Lithotripsy for Difficult Bile Duct Stones. <span><span class="ref-journal">J Laparoendosc Adv Surg Tech A. </span>2017 Jan;<span class="ref-vol">27</span>(1):24-27.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/28048950" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 28048950</span></a>]</div></dd><dt>33.</dt><dd><div class="bk_ref" id="article-34490.r33">Schatloff O, Rimon U, Garniek A, Lindner U, Morag R, Mor Y, Ramon J, Winkler H. Percutaneous transhepatic lithotripsy with the holmium: YAG laser for the treatment of refractory biliary lithiasis. <span><span class="ref-journal">Surg Laparosc Endosc Percutan Tech. </span>2009 Apr;<span class="ref-vol">19</span>(2):106-9.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/19390274" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 19390274</span></a>]</div></dd><dt>34.</dt><dd><div class="bk_ref" id="article-34490.r34">Alsolaiman MM, Reitz C, Nawras AT, Rodgers JB, Maliakkal BJ. Bouveret's syndrome complicated by distal gallstone ileus after laser lithotropsy using Holmium: YAG laser. <span><span class="ref-journal">BMC Gastroenterol. </span>2002 Jun 18;<span class="ref-vol">2</span>:15.</span> [<a href="/pmc/articles/PMC117132/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC117132</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/12086587" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 12086587</span></a>]</div></dd><dt>35.</dt><dd><div class="bk_ref" id="article-34490.r35">Pickhardt PJ, Friedland JA, Hruza DS, Fisher AJ. Case report. CT, MR cholangiopancreatography, and endoscopy findings in Bouveret's syndrome. <span><span class="ref-journal">AJR Am J Roentgenol. </span>2003 Apr;<span class="ref-vol">180</span>(4):1033-5.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/12646450" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 12646450</span></a>]</div></dd><dt>36.</dt><dd><div class="bk_ref" id="article-34490.r36">Rogart JN, Perkal M, Nagar A. Successful Multimodality Endoscopic Treatment of Gastric Outlet Obstruction Caused by an Impacted Gallstone (Bouveret's Syndrome). <span><span class="ref-journal">Diagn Ther Endosc. </span>2008;<span class="ref-vol">2008</span>:471512.</span> [<a href="/pmc/articles/PMC2239211/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC2239211</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/18493330" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 18493330</span></a>]</div></dd><dt>37.</dt><dd><div class="bk_ref" id="article-34490.r37">ASGE Technology Committee. Watson RR, Parsi MA, Aslanian HR, Goodman AJ, Lichtenstein DR, Melson J, Navaneethan U, Pannala R, Sethi A, Sullivan SA, Thosani NC, Trikudanathan G, Trindade AJ, Maple JT. Biliary and pancreatic lithotripsy devices. <span><span class="ref-journal">VideoGIE. </span>2018 Nov;<span class="ref-vol">3</span>(11):329-338.</span> [<a href="/pmc/articles/PMC6205352/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC6205352</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/30402576" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 30402576</span></a>]</div></dd><dt>38.</dt><dd><div class="bk_ref" id="article-34490.r38">Reinhardt SW, Jin LX, Pitt SC, Earl TM, Chapman WC, Doyle MB. Bouveret's syndrome complicated by classic gallstone ileus: progression of disease or iatrogenic? <span><span class="ref-journal">J Gastrointest Surg. </span>2013 Nov;<span class="ref-vol">17</span>(11):2020-4.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/24018589" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 24018589</span></a>]</div></dd><dt>39.</dt><dd><div class="bk_ref" id="article-34490.r39">Pavlidis TE, Atmatzidis KS, Papaziogas BT, Papaziogas TB. Management of gallstone ileus. <span><span class="ref-journal">J Hepatobiliary Pancreat Surg. </span>2003;<span class="ref-vol">10</span>(4):299-302.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/14598150" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 14598150</span></a>]</div></dd><dt>40.</dt><dd><div class="bk_ref" id="article-34490.r40">Gallego Otaegui L, Sainz Lete A, Gutiérrez Ríos RD, Alkorta Zuloaga M, Arteaga Martín X, Jiménez Agüero R, Medrano Gómez MÁ, Ruiz Montesinos I, Beguiristain Gómez A. A rare presentation of gallstones: Bouveret´s syndrome, a case report. <span><span class="ref-journal">Rev Esp Enferm Dig. </span>2016 Jul;<span class="ref-vol">108</span>(7):434-6.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/27659106" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 27659106</span></a>]</div></dd><dt>41.</dt><dd><div class="bk_ref" id="article-34490.r41">Stein PH, Lee C, Sejpal DV. A Rock and a Hard Place: Successful Combined Endoscopic and Surgical Treatment of Bouveret's Syndrome. <span><span class="ref-journal">Clin Gastroenterol Hepatol. </span>2015 Dec;<span class="ref-vol">13</span>(13):A25-6.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/26254202" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 26254202</span></a>]</div></dd><dt>42.</dt><dd><div class="bk_ref" id="article-34490.r42">Thompson RJ, Gidwani A, Caddy G, McKenna E, McCallion K. Endoscopically assisted minimally invasive surgery for gallstones. <span><span class="ref-journal">Ir J Med Sci. </span>2009 Mar;<span class="ref-vol">178</span>(1):85-7.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/17973154" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 17973154</span></a>]</div></dd><dt>43.</dt><dd><div class="bk_ref" id="article-34490.r43">Newton RC, Loizides S, Penney N, Singh KK. Laparoscopic management of Bouveret syndrome. <span><span class="ref-journal">BMJ Case Rep. </span>2015 Apr 22;<span class="ref-vol">2015</span></span> [<a href="/pmc/articles/PMC4420823/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC4420823</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/25903213" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 25903213</span></a>]</div></dd><dt>44.</dt><dd><div class="bk_ref" id="article-34490.r44">Yang D, Wang Z, Duan ZJ, Jin S. Laparoscopic treatment of an upper gastrointestinal obstruction due to Bouveret's syndrome. <span><span class="ref-journal">World J Gastroenterol. </span>2013 Oct 28;<span class="ref-vol">19</span>(40):6943-6.</span> [<a href="/pmc/articles/PMC3812499/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC3812499</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/24187475" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 24187475</span></a>]</div></dd><dt>45.</dt><dd><div class="bk_ref" id="article-34490.r45">Balakrishnan S, Samdani T, Singhal T, Hussain A, Grandy-Smith S, Nicholls J, El-Hasani S. Patient experience with gallstone disease in a national health service district hospital. <span><span class="ref-journal">JSLS. </span>2008 Oct-Dec;<span class="ref-vol">12</span>(4):389-94.</span> [<a href="/pmc/articles/PMC3016000/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC3016000</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/19275855" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 19275855</span></a>]</div></dd><dt>46.</dt><dd><div class="bk_ref" id="article-34490.r46">Hussain A. Difficult laparoscopic cholecystectomy: current evidence and strategies of management. <span><span class="ref-journal">Surg Laparosc Endosc Percutan Tech. </span>2011 Aug;<span class="ref-vol">21</span>(4):211-7.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/21857467" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 21857467</span></a>]</div></dd><dt>47.</dt><dd><div class="bk_ref" id="article-34490.r47">Jafferbhoy S, Rustum Q, Shiwani M. Bouveret's syndrome: should we remove the gall bladder? <span><span class="ref-journal">BMJ Case Rep. </span>2011 Apr 01;<span class="ref-vol">2011</span></span> [<a href="/pmc/articles/PMC3079472/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC3079472</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/22700609" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 22700609</span></a>]</div></dd><dt>48.</dt><dd><div class="bk_ref" id="article-34490.r48">Lee W, Han SS, Lee SD, Kim YK, Kim SH, Woo SM, Lee WJ, Koh YW, Hong EK, Park SJ. Bouveret's syndrome: a case report and a review of the literature. <span><span class="ref-journal">Korean J Hepatobiliary Pancreat Surg. </span>2012 May;<span class="ref-vol">16</span>(2):84-7.</span> [<a href="/pmc/articles/PMC4574991/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC4574991</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/26388913" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 26388913</span></a>]</div></dd><dt>49.</dt><dd><div class="bk_ref" id="article-34490.r49">Lopes CV, Lima FK, Hartmann AA. Bouveret syndrome and pancreatic acinar cell carcinoma. <span><span class="ref-journal">Endoscopy. </span>2017 Feb;<span class="ref-vol">49</span>(S 01):E62-E63.</span> [<a href="/pmc/articles/PMC8819734/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC8819734</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/28135730" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 28135730</span></a>]</div></dd><dt>50.</dt><dd><div class="bk_ref" id="article-34490.r50">Alemi F, Seiser N, Ayloo S. Gallstone Disease: Cholecystitis, Mirizzi Syndrome, Bouveret Syndrome, Gallstone Ileus. <span><span class="ref-journal">Surg Clin North Am. </span>2019 Apr;<span class="ref-vol">99</span>(2):231-244.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/30846032" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 30846032</span></a>]</div></dd><dt>51.</dt><dd><div class="bk_ref" id="article-34490.r51">Ploneda-Valencia CF, Gallo-Morales M, Rinchon C, Navarro-Muñiz E, Bautista-López CA, de la Cerda-Trujillo LF, Rea-Azpeitia LA, López-Lizarraga CR. Gallstone ileus: An overview of the literature. <span><span class="ref-journal">Rev Gastroenterol Mex. </span>2017 Jul-Sep;<span class="ref-vol">82</span>(3):248-254.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/28433486" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 28433486</span></a>]</div></dd><dt>52.</dt><dd><div class="bk_ref" id="article-34490.r52">Saldaña Dueñas C, Fernández-Urien I, Rullán Iriarte M, Vila Costa JJ. Laser lithotripsy resolution for Bouveret syndrome. <span><span class="ref-journal">Endoscopy. </span>2017 Feb;<span class="ref-vol">49</span>(S 01):E101-E102.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/28192808" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 28192808</span></a>]</div></dd><dt>53.</dt><dd><div class="bk_ref" id="article-34490.r53">Bhattarai M, Bansal P, Patel B, Lalos A. Exploring the Diagnosis and Management of Bouveret's Syndrome. <span><span class="ref-journal">JNMA J Nepal Med Assoc. </span>2016 Jan-Mar;<span class="ref-vol">54</span>(201):33-35.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/27935909" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 27935909</span></a>]</div></dd></dl></div><div><dl class="temp-labeled-list small"><dt></dt><dd><div><p class="no_top_margin">
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<b>Disclosure: </b>Anisha Turner declares no relevant financial relationships with ineligible companies.</p></div></dd><dt></dt><dd><div><p class="no_top_margin">
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<b>Disclosure: </b>Pujitha Kudaravalli declares no relevant financial relationships with ineligible companies.</p></div></dd><dt></dt><dd><div><p class="no_top_margin">
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<b>Disclosure: </b>Jasim Al-Musawi declares no relevant financial relationships with ineligible companies.</p></div></dd><dt></dt><dd><div><p class="no_top_margin">
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<b>Disclosure: </b>Hira Ahmad declares no relevant financial relationships with ineligible companies.</p></div></dd></dl></div><div class="bk_prnt_sctn"><h2>Figures</h2><div class="whole_rhythm bk_prnt_obj bk_first_prnt_obj"><div id="article-34490.image.f1" class="figure bk_fig"><div class="graphic"><img src="/books/NBK430738/bin/migrating__stone.jpg" alt="Gallstone Ileus in the Jejunum" /></div><div class="caption"><p>Gallstone Ileus in the Jejunum. This is an image of a gallstone extracted after migrating and causing gallstone ileus in the jejunum. Contributed by J Al-Musawi, MD</p></div></div></div><div class="whole_rhythm bk_prnt_obj"><div id="article-34490.image.f2" class="figure bk_fig"><div class="graphic"><a href="/core/lw/2.0/html/tileshop_pmc/tileshop_pmc_inline.html?title=Bouveret%20Syndrome%20With%20Rigler%20Triad&p=BOOKS&id=430738_CT__bouveret__syndrome__pneumobilia.jpg" target="tileshopwindow" class="inline_block pmc_inline_block ts_canvas img_link" title="Click on image to zoom"><div class="ts_bar small" title="Click on image to zoom"></div><img src="/books/NBK430738/bin/CT__bouveret__syndrome__pneumobilia.jpg" alt="Bouveret Syndrome With Rigler Triad" class="tileshop" title="Click on image to zoom" /></a></div><div class="caption"><p>Bouveret Syndrome With Rigler Triad. Initial computed tomography of the abdomen revealed typical Bouveret syndrome with Rigler triad. (1) pneumobilia, (2) collapse of the gallbladder, (3) ectopic gallstone in the proximal duodenum, size more than 4 cm, (4) distended stomach. Contributed by J Al-Musawi, MD</p></div></div></div><div class="whole_rhythm bk_prnt_obj"><div id="article-34490.image.f3" class="figure bk_fig"><div class="graphic"><a href="/core/lw/2.0/html/tileshop_pmc/tileshop_pmc_inline.html?title=Computed%20Tomography%20of%20the%20Abdomen%2C%20Cholecystoduodenal%20Fistula&p=BOOKS&id=430738_CT__bouveret__syndrome__fistula.jpg" target="tileshopwindow" class="inline_block pmc_inline_block ts_canvas img_link" title="Click on image to zoom"><div class="ts_bar small" title="Click on image to zoom"></div><img src="/books/NBK430738/bin/CT__bouveret__syndrome__fistula.jpg" alt="Computed Tomography of the Abdomen, Cholecystoduodenal Fistula" class="tileshop" title="Click on image to zoom" /></a></div><div class="caption"><p>Computed Tomography of the Abdomen, Cholecystoduodenal Fistula. This is computed tomography of the abdomen for a patient with Bouveret syndrome, showing a cholecystoduodenal fistula (shown by an arrow). Contributed by J Al-Musawi, MD</p></div></div></div><div class="whole_rhythm bk_prnt_obj"><div id="article-34490.image.f4" class="figure bk_fig"><div class="graphic"><a href="/core/lw/2.0/html/tileshop_pmc/tileshop_pmc_inline.html?title=Migrated%20Gallstone%20After%20Endoscopic%20Lithotripsy&p=BOOKS&id=430738_CT__bouveret__syndrome__ileus.jpg" target="tileshopwindow" class="inline_block pmc_inline_block ts_canvas img_link" title="Click on image to zoom"><div class="ts_bar small" title="Click on image to zoom"></div><img src="/books/NBK430738/bin/CT__bouveret__syndrome__ileus.jpg" alt="Migrated Gallstone After Endoscopic Lithotripsy" class="tileshop" title="Click on image to zoom" /></a></div><div class="caption"><p>Migrated Gallstone After Endoscopic Lithotripsy. Computed tomography of the abdomen shows a migrated gallstone after endoscopic lithotripsy, which caused gallstone ileus in the proximal jejunum. Contributed by Jasim Al-Musawi, MD</p></div></div></div><div class="whole_rhythm bk_prnt_obj"><div id="article-34490.image.f5" class="figure bk_fig"><div class="mp-outer"><div class="ncbimedia" id="_bk_plyr_media-1"><video preload="none" poster="/corehtml/pmc/flowplayer/player-splash.jpg" height="360" width="270"><source src="/books/NBK430738/bin/Bouveret__syndrom__video-pmcvs_normal.flv" type="video/flash"></source><source src="/books/NBK430738/bin/Bouveret__syndrom__video-pmcvs_normal.mp4" type="video/mp4"></source><source src="/books/NBK430738/bin/Bouveret__syndrom__video-pmcvs_normal.webm" type="video/webm"></source></video></div></div><div class="half_rhythm"><a href="/books/NBK430738/bin/Bouveret__syndrom__video.mp4">Download</a> video file.<sup>(8.0M, mp4)</sup></div><div class="caption"><p>Bouveret Syndrome Treatment With Endoscopic Laser Lithotripsy Contributed by J Al-Musawi, MD</p></div></div></div></div></div></div>
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