Which biliary pathology involves a large gallstone passing into the duodenum to cause gastric outlet obstruction, typically with a cholecystoenteric fistula?

Which biliary pathology involves a large gallstone passing into the duodenum to cause gastric outlet obstruction, typically with a cholecystoenteric fistula?

• A. Mirizzi Syndrome
• B. Gallstone ileus
• C. Courvoisier gallbladder
• D. Bouveret Syndrome

Answer: (D)

Bouveret syndrome is a proximal form of gallstone ileus in which a large gallstone passes from the gallbladder into the gastrointestinal tract through a cholecystoenteric fistula and becomes impacted at the gastric outlet (pylorus or proximal duodenum), causing obstruction. This specific location—gastric outlet obstruction caused by a gallstone that has entered the bowel via a fistula—defines the condition. Chronic inflammation often forms the fistula between the gallbladder and the duodenum or stomach, allowing the stone to migrate. Clinically, patients may have nausea, vomiting, and epigastric pain. Imaging might show a radiopaque or radiolucent stone in the duodenum with signs of obstruction and pneumobilia (the Rigler triad in gallstone–related enteric fistulas can be seen, though not always). This differs from Mirizzi syndrome, where a stone in the gallbladder neck compresses the common hepatic duct without a biliary-enteric fistula and causes jaundice; Courvoisier gallbladder describes a palpable, distended gallbladder in the setting of distal biliary obstruction, not a fistula or proximal obstruction; and gallstone ileus refers to a gallstone causing small bowel obstruction generally in the ileum, not specifically at the gastric outlet.

Bouveret syndrome is a proximal form of gallstone ileus in which a large gallstone passes from the gallbladder into the gastrointestinal tract through a cholecystoenteric fistula and becomes impacted at the gastric outlet (pylorus or proximal duodenum), causing obstruction. This specific location—gastric outlet obstruction caused by a gallstone that has entered the bowel via a fistula—defines the condition.

Chronic inflammation often forms the fistula between the gallbladder and the duodenum or stomach, allowing the stone to migrate. Clinically, patients may have nausea, vomiting, and epigastric pain. Imaging might show a radiopaque or radiolucent stone in the duodenum with signs of obstruction and pneumobilia (the Rigler triad in gallstone–related enteric fistulas can be seen, though not always).

This differs from Mirizzi syndrome, where a stone in the gallbladder neck compresses the common hepatic duct without a biliary-enteric fistula and causes jaundice; Courvoisier gallbladder describes a palpable, distended gallbladder in the setting of distal biliary obstruction, not a fistula or proximal obstruction; and gallstone ileus refers to a gallstone causing small bowel obstruction generally in the ileum, not specifically at the gastric outlet.