According to phonejust, the Bouveret syndrome is a gallstone disease, stomach can be blocked in the sequence of output. This clinical picture occurs rarely, but is extremely life-threatening for the patient. A large gallstone travels through a fistula in the gallbladder into the duodenum, so that it lies on the stomach outlet. This process is triggered by an inflammation. The disease is named after the French doctor Léon Bouveret (1850-1929), who described it classically in 1896.

What is Bouveret Syndrome?

The formation of gallstones is related to the bile that is produced in the liver and stored in the gallbladder. This thick secretion is used for digestion and is released into the intestines. It ensures the elimination of toxins and metabolic degradation products. Most of the bile consists of water, which dissolves the other components of the liquid, such as cholesterol.

These substances are in a very specific proportion to each other. If this balance is disturbed, crystals form in the bile that can grow into gallstones. The same thing happens when the bile cannot drain away, for example due to a narrowing or even an obstruction in the so-called bile duct. A condition of this type is known as Bouveret’s syndrome.

Causes

This can result in biliary colic, if a stone from the gallbladder has entered the bile duct, causing a blockage there. In an effort to remove this foreign body, the muscles of the bile duct contract in spasms. This process causes severe cyclical pain called biliary colic.

In addition to the pain, the build-up of the bile represents a major health risk. Under certain circumstances it will drain into the liver or even to the pancreas, and can thus cause dangerous inflammation in the entire abdomen. If such signs build up, a precautionary removal of the gallbladder is often the only possible escape route.

The patients are mostly women over the age of 70 who experience sudden severe pain in the abdomen, combined with severe nausea and nervous vomiting. Unnatural fever outbreaks and chills can be associated with these symptoms. In some cases there is also jaundice, especially the yellowing of the skin. For a long time, these and other possible parallel diseases made a reliable diagnosis of Bouveret’s syndrome difficult.

Symptoms, ailments & signs

Nowadays, imaging methods, such as sonography (ultrasound examination) or computed tomography, point out the causes of the disease with great accuracy. Air bubbles in the biliary tract, which arise in connection with the formation of fistulas in the intestinal area, can be shown very well. In Bouveret’s syndrome, the occlusion forms relatively high up at the exit of the stomach. In this way, the inflammation features can be localized very clearly.

Diagnosis & course

The therapy is initially based on a gentle approach. Bouveret’s syndrome occurs predominantly in older people, who often suffer from several comorbidities. Therefore, depending on the initial clinical situation, breaking up the gallstone and then removing it is preferable to an operative procedure. The doctor usually uses a simple mirroring with the endoscope.

If surgery is unavoidable, it should be limited to removing the stone and restoring the natural passage, if possible. The risks of removing the gallbladder and occluding the fistula are often disproportionately high. In Bouveret’s syndrome, the gall bladder is typically inflamed and the fistula to the duodenum is filled with gas.

With the help of endoscopy, the gallstone can be minimized by targeted detachments at its edges. Either it has become so small that it can be retrieved orally, or it slides deeper until it is excreted in the usual ways. If the course is favorable and antibacterial treatment is used, the fistula can then resolve on its own within a few days.

If these prospects are not fulfilled, the fistula can be sutured over. However, it has been statistically proven that postoperative complications have been observed in one third of all cases. These are mainly wound infections. The safety is greatest when the gastric occlusive gallstone alone is removed.

Today surgeons see this as a sensible alternative to more extensive renovations, for example the fistula. A large gallstone can measure around seven by three centimeters. This means that gastric emptying is massively blocked in an emergency with Bouveret’s syndrome.

Complications

Bouveret’s syndrome is a very rare complication of a bile duct blockage caused by a stone. The stone gets into the duodenum via a connection (fistula) and can thus close the gastric outlet (pylorus) and thus cause a stenosis. This complication is characterized by sudden nausea and vomiting as well as severe pain in the upper part of the abdomen.

The stenosis of the gastric outlet can cause the worst metabolic derailments, which can even be life-threatening if they are not treated surgically. Frequent vomiting causes metabolic alkalosis in the body and the risk of dehydration, as a lot of fluid is lost and hardly any is absorbed.

In an unclean operation, the wound can become infected and put additional strain on the body. Internal bleeding can also occur. Furthermore, the stomach can become inflamed; in the worst case, the inflammation can spread systemically and thus cause sepsis. The Sepsis is a life-threatening condition and will need immediate treatment with medication, as this can lead to death of the patient fast.

In general, gallstones increase the risk of inflammation of the bile ducts and gallbladder, which can also lead to sepsis. The stone can also penetrate the walls and lead to inflammation of the peritoneum (peritonitis).

When should you go to the doctor?

Bouveret’s syndrome is a gallstone disease that blocks the stomach outlet. Medical and drug treatment is urgently required, as there can even be an acute danger to life. In most cases, Bouveret’s syndrome occurs in older people who have previously had problems with existing gallstones. The difficulty with Bouveret’s syndrome is that this clinical picture is often diagnosed very late.

Often the Bouveret syndrome is noticeable through severe and long-lasting abdominal pain. In addition, there is often a sharp pain in the abdominal region, which severely restricts everyday life. For this reason, a doctor should be consulted as soon as possible in the event of inexplicable abdominal pain. If you do not visit the doctor at this point, you are putting yourself at great risk. The bulging pains increase significantly in such a case.

An increased temperature and nausea are also possible side effects that can occur in connection with the clinical picture described above. For this reason, the following applies: Bouveret’s syndrome is a clinical picture that definitely requires medical attention.

Treatment & Therapy

Usually, a gallstone is only the size of a cherry pit. It consists essentially of solidified bile. It is mainly formed from deposited cholesterol, so that it is yellowish in color. It is estimated that around 20 percent of gallstones are so-called pigment stones.

Its core also consists of cholesterol, around which the bile pigment bilirubin has settled. Pigment stones are only as small as grains of sand, but they occur in larger colonies. All different gallstones have in common that they calcify in the course of life.

Outlook & forecast

Bouveret’s syndrome is a medical emergency. Treatment must begin quickly, otherwise it can be fatal. In the majority of cases, older women over the age of 70 are affected. Due to their age, those affected usually also suffer from other diseases, which can additionally worsen the prognosis.

In the case of Bouveret’s syndrome, a gallstone moves through a fistula that connects the bile duct and duodenum in front of the gastric outlet and blocks it. The fistula is formed by inflammatory processes in the context of biliary tract disease. In addition to the abdominal discomfort that occurs suddenly, there may be further complications, including peritonitis.

Only a quick removal or shattering of the gallstone can end the extremely life-threatening condition. After successfully removing the stone, depending on the general physical condition of the patient, there is usually complete healing.

Since these are usually elderly patients with other concomitant diseases, therapy must be applied that is as gentle as possible. If possible, the stone is smashed and removed with endoscopic help. Otherwise, an operation will have to be performed to remove the stone from the gastric outlet, whereby the only aim should then be to restore patency. In this case, major surgery involving removal of the gallbladder should be avoided in order not to increase the risk of surgery.

Prevention

In Germany, gallstones occur statistically in about every sixth inhabitant. They form much more frequently in women than in men. However, only around 25 percent of all those affected have noticeable complaints. If gallstones don’t cause symptoms, they don’t need treatment.

The stones are then probably responsible for the first pain in the upper abdomen, which can also extend to the back and right shoulder area. A cholesterol-conscious diet is the best way to prevent biliary problems.

You can do that yourself

Bouveret’s syndrome is a rare complication that requires immediate hospital treatment. After the gallstone has been successfully removed, those affected should initially take it easy. Bed rest and a healthy, not too irritating diet should regulate the gastrointestinal tract again in a short time. To rinse out residues of kidney or bile grits, plenty of water or kidney tea should be drunk. Herbal teas and massages help with pain, but also warm pads, physical exercise or a visit to the sauna.

In consultation with the doctor, the causes of Bouveret’s syndrome should also be determined. Often the complication is due to another disease that needs to be treated accordingly. The doctor responsible usually recommends dietary measures such as avoiding stimulants or generally recommends a healthier lifestyle.

Older patients may also have to change their medication. Various preparations help to break down gallstones and reduce the pain that can result. Home remedies such as warm beer or cranberry juice are an alternative. If, in spite of all the measures, severe discomfort occurs, you must see a doctor with Bouveret’s syndrome.

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