[Sonographic diagnosis of Bouveret's syndrome].

MEDICAL HISTORY

A 76-year-old woman with known dementia was admitted to hospital for postprandial vomiting and increasing upper abdominal pain for 2 days. Gallstones and a chronic cholecystitis had been previously documented.

INVESTIGATIONS

Laboratory tests revealed slight hypochromic anemia (Hb 10.6 g/dl) and an increase in gammaGT (439 U/l) and AP (277 U/l) with a normal bilirubin. The gall bladder was very small sonographically, compared to an examination 6 months earlier. Furthermore, there was a marked aerobilia in the peripheral bile ducts.

DIAGNOSIS

Bouveret;s syndrome, with a 6 cm concrement in the duodenal bulb, was suspected at the initial ultrasound examination and confirmed by endoscopy and radiology. TREATMENT AND FOLLOW-UP: When the patient was operated the following day, a chronically inflamed gall bladder with perforation into the duodenum was found, but no concrement in the duodenal bulb. The operative field was extended and revealed a distal small bowel obstruction caused by an incarcerated stone at the ileocecal valve. The concrement was removed and a cholecystectomy with closure of the fistula performed. However, 8 days later the patient died from multiorgan failure.

CONCLUSION

This was a rare case of a "classical" Bouveret's syndrome that spontaneously changed into a distal small bowel obstruction by gall stones. In an appropriate clinical setting, this condition can be diagnosed by a simple abdominal ultrasound examination.