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\begin{document}

\title{Bouveret syndrome - a rare variant of gallstone ileus}



\author[1]{Ana Alves}%
\author[1]{João Louro}%
\author[1]{Raquel Maia}%
\affil[1]{Centro Hospitalar do Porto}%


\vspace{-1em}



  
  \date{June 02, 2024}


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\selectlanguage{english}
\begin{abstract}
Bouveret syndrome is a rare cause of gastric outlet obstruction by
passage of gallstone through a fistula between the gallbladder and
proximal gastrointestinal tract, it is considered a proximal form of
gallstone ileus. The clinical presentation is nonspecific, and imaging
plays an important role in the diagnosis of this entity.%
\end{abstract}%



\sloppy


\textbf{Title}

Bouveret syndrome - a rare variant of gallstone ileus

\textbf{Authors}

Ana Margarida Alves\textsuperscript{1}, Jo\selectlanguage{ngerman}ão Louro\textsuperscript{1},
Raquel Maia\textsuperscript{1}

\textsuperscript{1}Radiology Department, Centro Hospitalar Universitário
do Porto, Porto, Portugal

\textbf{Correspondence}

Ana Margarida Alves

Radiology Department, Centro Hospitalar Universitário do Porto

Largo do Prof. Abel Salazar, 4099-001 Porto, Portugal

Email: anamargarida.ca@gmail.com

\textbf{Keywords}

Bouveret syndrome, gastric outlet obstruction, gallstones, case report

\textbf{Key Clinical Message}

Bouveret syndrome is a rare entity and should be taken into
consideration as a differential diagnosis of proximal gastric outlet
obstruction. CT examination is considered the gold standard, but an
abdominal radiography can make the diagnosis.

\textbf{Abstract}

Bouveret syndrome is a rare cause of gastric outlet obstruction by
passage of gallstone through a fistula between the gallbladder and
proximal gastrointestinal tract, it is considered a proximal form of
gallstone ileus. The clinical presentation is nonspecific, and imaging
plays an important role in the diagnosis of this entity.

\textbf{Main Text}

An 85-year-old man presented to Emergency Department~with a history of
epigastric pain and vomiting for 2 days. On physical examination, his
abdomen was distended and painful to palpation. Laboratory findings
showed raised inflammatory markers.

Plain abdominal radiograph (Figure 1) showed gastric distension with
air-fluid level, pneumobilia and an ectopic calcified gallstone in the
lower right quadrant. This represents the Rigler triad, suggesting
gallstone ileus. Contrast-enhanced CT (Figure 2) revealed marked gastric
distension and stasis conditioned by a 4cm gallstone in the level D3 of
duodenum. CT also showed cholelithiasis and a
cholecystoduodenal~fistula. In addition to pneumobilia, there was also
pneumoportia and associated pneumatosis of the gastric wall, suggesting
ischemia due to acute massive distension. Subsequently, the patient was
submitted to open~entero-lithotomy, but died 13 days later.

Bouveret syndrome is a rare subset of gallstone ileus that presents with
gastric outlet obstruction secondary to impaction of a gallstone in the
pylorus or proximal duodenum, via an acquired cholecystoenteric
fistula\textsuperscript{1}. In addition to the Rigler triad, CT can also
depict the fistula, number and location of the gallstones, status of the
gallbladder, level and degree of obstruction and signs of ischemia, that
are important factors for the treatment decision\textsuperscript{2}.

\textbf{Authors' Contribution}

Author 1: wrote the article, made the literature review, and edited the
images.

Author 2 and 3: edited the images and reviewed the manuscript.

\textbf{Conflict of Interest Statement}

None declared.

\textbf{References}

1 - Mavroeidis VK, Matthioudakis DI, Economou NK, Karanikas ID. Bouveret
syndrome-the rarest variant of gallstone ileus: a case report and
literature review.~\emph{Case Rep Surg} . 2013;2013:839370.
doi:10.1155/2013/839370

2 - Yu YB, Song Y, Xu JB, Qi FZ. Bouveret's syndrome: A rare
presentation of gastric outlet obstruction.~\emph{Exp Ther Med} .
2019;17(3):1813-1816. doi:10.3892/etm.2019.7150

\textbf{Figure legends~}

\textbf{Figure 1 --} Abdominal radiograph in seated position shows
gastric distension with air-fluid level (asterix), pneumobilia (arrow)
and an ectopic calcified gallstone in the lower right quadrant
(arrowhead) -- Rigler triad.

\textbf{Figure 2 -} Coronal image of contrast-enhanced abdominal CT
shows marked gastric stasis and distension conditioned by a gallstone
(arrowhead) in the level D3 of duodenum and the cholecystoduodenal
fistula (arrow). CT also depict pneumatosis of the gastric wall (open
arrowhead) and associated pneumoportia (open arrow), suggesting ischemia
due to acute massive distension.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-1/Figure-1}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-2/Figure-2}

\end{center}
\end{figure}

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