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Endoscopic treatment of Bouveret's syndrome
At the Focal Point
Commentary In 1896, Leon Bouveret described 2 patients with gastric outlet obstruction produced by a large gallstone impacted in the distal stomach/proximal duodenum. The proximate cause of this obstruction is a fistula, which develops after the inflamed gallbladder becomes adherent to its common anatomic resting place, the superior portion of the postbulbar duodenum. As if gastric outlet obstruction weren’t enough, vomiting can trigger Boerhaave’s syndrome, and fragmentation of the stone can be complicated by gallstone ileus. Because the impacted stone usually is very large, therapy can be both challenging and frustrating. Stone extraction with a basket or net or lithotripsy has been used, but surgery is often, as in the present case, required; in such cases, surgical extirpation of the stone should not be viewed as an endoscopic failure, but rather as prudent judgment. What should be done with the gallstone after removing it? Most of us send it, along with the gallbladder, to surgical pathology for processing. It might be useful to know, however, that gallstones are a valuable byproduct of meat processing and have fetched (illegally) up to $900 US an ounce for use as an aphrodisiac. Alas, the finest gallstones are not from humans but from old dairy cows. Lawrence J. Brandt, MD Associate Editor for Focal Points
Endoscopic treatment of Bouveret’s syndrome
A 65-year-old woman was admitted to our hospital for severe epigastric pain, vomiting, and nausea. She had a history of gallbladder disease, with recurrent abdominal pain, and had recently developed high fevers. Clinical examination did not show signs of peritonitis. An abdominal US suggested the diagnosis of a biliary fistula, and CT scan (A) demonstrated a thickened pyloric wall in continuity with
the anatomic site of the gallbladder (although the gallbladder was not identified), aerobilia, and a large gallstone floating in the stomach. Endoscopy (B) revealed a stone in the pyloric area. A barium contrast study (C) confirmed the presence of a cholecystoduodenal fistula with a gallstone in the pylorus. Because of its large size, which did not allow one-step removal, endoscopic lithotomy was performed,
704 GASTROINTESTINAL ENDOSCOPY Volume 65, No. 4 : 2007
www.giejournal.org
At the Focal Point
followed-up by endoscopic extraction (D) of the gastric gallstone fragments (E) by use of a Dormia basket. The postendoscopic course was smooth, without need for further intervention.
DISCLOSURE The authors have no conflicts of interest to disclosure.
www.giejournal.org
Andrea Polistena, MD, Dipartimento di Chirurgia ‘‘PietroValdoni’’, Universita` ‘‘La Sapienza’’, Roma; Francesco Santi, MD, Dipartimento di Chirurgia, Ospedale Regina Apostolorum, Albano Laziale (Roma); Riccardo Tiberi, MD, Universita` ‘‘La Sapienza’’, Roma; Maurizio Bagarani, MD, Dipartimento di Chirurgia, Ospedale Regina Apostolorum, Albano Laziale (Roma), Italy doi:10.1016/j.gie.2006.12.022
Volume 65, No. 4 : 2007 GASTROINTESTINAL ENDOSCOPY 705
At the Focal Point
Commentary Gallstones that obstruct the gastric outlet are akin to glacial boulders or ‘‘erratics,’’ defined by geologists as stones or boulders that have been carried from their place of origin by a glacier and then left stranded by melting ice on bedrock of a different composition. Even the word boulder, which was probably of Scandinavian origin, from the dialectal Swedish ‘‘bullersten,’’ meaning ‘‘noisy stone,’’ has a resemblance to the clinical presentation of patients with Bouveret’s syndrome: imagine a large stone in a stream, causing water to roar around it, and then think of the patient with gastric borborygmi and retching as the impacted stone stimulates an assortment of movement, reflexes, and loud noises. In this case, it took 3 parties to manage the problem: Mother Nature moved the stone into the stomach where the endoscopist could fracture and grab it. Now the surgeon must complete therapy with a cholecystectomy and repair of the fistula. Lawrence J. Brandt, MD Associate Editor for Focal Points
Subepithelial gastric lesions: don’t forget to look behind the stomach!
Two men, aged 63 years (patient A) and 36 years (patient B), presented to our hospital with a 1-day history of hematemesis. Patient A had no significant medical history, whereas patient B required hospitalization 12 years previously because of alcoholic pancreatitis. Clinical examinations
were unremarkable in both patients other than tachycardia and orthostatic hypotension. Both patients were anemic and required blood transfusion; other laboratory data results were normal. Gastroscopies, performed within 12 hours of presentation, revealed similar-appearing posterior gastric-
706 GASTROINTESTINAL ENDOSCOPY Volume 65, No. 4 : 2007
www.giejournal.org
Commentary In 1896, Leon Bouveret described 2 patients with gastric outlet obstruction produced by a large gallstone impacted in the distal stomach/proximal duodenum. The proximate cause of this obstruction is a fistula, which develops after the inflamed gallbladder becomes adherent to its common anatomic resting place, the superior portion of the postbulbar duodenum. As if gastric outlet obstruction weren’t enough, vomiting can trigger Boerhaave’s syndrome, and fragmentation of the stone can be complicated by gallstone ileus. Because the impacted stone usually is very large, therapy can be both challenging and frustrating. Stone extraction with a basket or net or lithotripsy has been used, but surgery is often, as in the present case, required; in such cases, surgical extirpation of the stone should not be viewed as an endoscopic failure, but rather as prudent judgment. What should be done with the gallstone after removing it? Most of us send it, along with the gallbladder, to surgical pathology for processing. It might be useful to know, however, that gallstones are a valuable byproduct of meat processing and have fetched (illegally) up to $900 US an ounce for use as an aphrodisiac. Alas, the finest gallstones are not from humans but from old dairy cows. Lawrence J. Brandt, MD Associate Editor for Focal Points
Endoscopic treatment of Bouveret’s syndrome
A 65-year-old woman was admitted to our hospital for severe epigastric pain, vomiting, and nausea. She had a history of gallbladder disease, with recurrent abdominal pain, and had recently developed high fevers. Clinical examination did not show signs of peritonitis. An abdominal US suggested the diagnosis of a biliary fistula, and CT scan (A) demonstrated a thickened pyloric wall in continuity with
the anatomic site of the gallbladder (although the gallbladder was not identified), aerobilia, and a large gallstone floating in the stomach. Endoscopy (B) revealed a stone in the pyloric area. A barium contrast study (C) confirmed the presence of a cholecystoduodenal fistula with a gallstone in the pylorus. Because of its large size, which did not allow one-step removal, endoscopic lithotomy was performed,
704 GASTROINTESTINAL ENDOSCOPY Volume 65, No. 4 : 2007
www.giejournal.org
At the Focal Point
followed-up by endoscopic extraction (D) of the gastric gallstone fragments (E) by use of a Dormia basket. The postendoscopic course was smooth, without need for further intervention.
DISCLOSURE The authors have no conflicts of interest to disclosure.
www.giejournal.org
Andrea Polistena, MD, Dipartimento di Chirurgia ‘‘PietroValdoni’’, Universita` ‘‘La Sapienza’’, Roma; Francesco Santi, MD, Dipartimento di Chirurgia, Ospedale Regina Apostolorum, Albano Laziale (Roma); Riccardo Tiberi, MD, Universita` ‘‘La Sapienza’’, Roma; Maurizio Bagarani, MD, Dipartimento di Chirurgia, Ospedale Regina Apostolorum, Albano Laziale (Roma), Italy doi:10.1016/j.gie.2006.12.022
Volume 65, No. 4 : 2007 GASTROINTESTINAL ENDOSCOPY 705
At the Focal Point
Commentary Gallstones that obstruct the gastric outlet are akin to glacial boulders or ‘‘erratics,’’ defined by geologists as stones or boulders that have been carried from their place of origin by a glacier and then left stranded by melting ice on bedrock of a different composition. Even the word boulder, which was probably of Scandinavian origin, from the dialectal Swedish ‘‘bullersten,’’ meaning ‘‘noisy stone,’’ has a resemblance to the clinical presentation of patients with Bouveret’s syndrome: imagine a large stone in a stream, causing water to roar around it, and then think of the patient with gastric borborygmi and retching as the impacted stone stimulates an assortment of movement, reflexes, and loud noises. In this case, it took 3 parties to manage the problem: Mother Nature moved the stone into the stomach where the endoscopist could fracture and grab it. Now the surgeon must complete therapy with a cholecystectomy and repair of the fistula. Lawrence J. Brandt, MD Associate Editor for Focal Points
Subepithelial gastric lesions: don’t forget to look behind the stomach!
Two men, aged 63 years (patient A) and 36 years (patient B), presented to our hospital with a 1-day history of hematemesis. Patient A had no significant medical history, whereas patient B required hospitalization 12 years previously because of alcoholic pancreatitis. Clinical examinations
were unremarkable in both patients other than tachycardia and orthostatic hypotension. Both patients were anemic and required blood transfusion; other laboratory data results were normal. Gastroscopies, performed within 12 hours of presentation, revealed similar-appearing posterior gastric-
706 GASTROINTESTINAL ENDOSCOPY Volume 65, No. 4 : 2007
www.giejournal.org