Impacted gallstone at the duodenum: Surgical resolution of Bouveret’s syndrome in the elderly

Abstract

Bouveret’s Syndrome is a rare form of gallstone ileus resulting in gastric outlet obstruction due to migration of a gallstone through a bilioenteric fistula. It most commonly affects elderly female patients and poses diagnostic and therapeutic challenges due to its nonspecific clinical presentation. This report aims to present the case of an elderly female who came with persistent vomiting and upper abdominal pain for 3 weeks, worsening over one week. Contrast-enhanced CT revealed a 4 cm gallstone lodged at the D2-D3 junction, causing duodenal obstruction and proximal distension. Endoscopic evaluation was deferred due to clinical instability and stone’s location and size, above careful consideration using clinical pre-operative tools. She underwent urgent exploratory laparotomy for stone retrieval, and a Heineke-Mikulicz pyloroplasty was performed. While endoscopic treatment is often used, this case highlights the importance of surgical intervention in large, impacted stones or in clinically unstable patients. In this case, CT scan provided a clear diagnosis, and surgical intervention was both necessary and effective. Given the rarity of Bouveret’s Syndrome and its variable presentation, this report contributes to existing literature by reinforcing the importance of high clinical suspicion, timely imaging, and individualized surgical decision-making.