Abstract

We describe the first case in the literature of Bouveret’s syndrome as the result of a cholecystoduodenocolic fistula secondary to gallbladder carcinoma. A 67-years-old woman was admitted to our department presenting with complaints of severe cramping abdominal pain, localized predominantly in the right hypochondrium and epigastrium, with infrequent alimentary and biliary vomiting for about three months. Based on the radiological and endoscopic findings, the provisional diagnosis of Bouveret’s syndrome in a patient with cholecystoduodenal fistula and history of cholelithiasis was made. The laparotomy showed the presence of the stone in the duodenal bulb, already seen at endoscopy, and adhesions between gallbladder, superior duodenal flexure and hepatic flexure of the colon, and this inflammatory gangue strethed up to the hepatic hilum. During dissection in addition to the communication between the gallbladder and the duodenum, another fistula was found that led from the gallbladder to the colon. The suspicion of malignancy of this multiple biliary enteric fistula was confirmed by intraoperative frozen sections that revealed the precence of a poorly differentiated carcinoma of biliary-pancreatic origin, but the ultimate diagnosis of gallbladder carcinoma was made exclusively after the definitive histopathological examination. For these reasons the surgical procedure involved cholecystectomy with resection of the regional lymph nodes, gastrotomy with extraction of gallstone, trans-mesocolic Roux-en-Y gastro-jejunal mechanical anastomosis, resection of the hepatic flexure of the colon with termino-lateral colo-colic mechanical anastomosis. It’s important to remember that rarely the Bouveret’s syndrome can hide multiple biliary enteric fistulas or even a malignancy. We believe, in the light of our experience, that the surgical approach represents the first choice in the treatment of this serious disease.