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Where did the Gallstones go?

Clinical scenario:
             An 88-year-old  male with no co morbid illness  presented to the emergency department at King Fahad Medical City , Riyadh, with chief complaints of postprandial fullness and on-and-off vomiting of  one month duration. 
            One year back he had developed pain abdomen and was diagnosed to have cholecystitis Ultrasound at that time showed two  gall stones without biliary dilatation . He had been managed in a local hospital and discharged home at that time . 
The patient denied having had any abdominal surgery  or endoscopic procedure prior to current  presentation.
On examination: 
The patient was thin built  mildly dehydrated with normal vitals. Abdominal examination revealed no surgical scar.There was  fullness in the upper abdomen but abdomen was  soft, not tender and there was no organomegaly or ascites. Succession splash  was positive. Bowel sounds were normal
 Systemic  exam was unremarkable. 
Laboratory investigations revealed a hemoglobin of 14gm/dl , white  cell and platelet count were normal .The patient had features of pre-renal azotemia which normalized after fluid therapy. 
His liver function tests were normal too. After an overnight fast and Ryles tube aspiration an upper GI endoscopic examination was done.Endoscopy  revealed evidence of retained  liquid in the stomach despite of overnight fast and approximately 1200 ml of fluid was aspirated. A tight stenosis was noted at the pylorus. Only a pediatric diagnostic scope could successfully negotiate the pylorus. The duodenal bulb was deformed, inflamed, and stenotic. An opening was noted at the junction of the duodenal bulb and the second part of the duodenum, with the ampulla lying in very close proximity to this opening. (Fig. 1)
Fig 1 Endoscopy showing opening in duodenal area

Later CT scan abdomen was done which revealed pnumobilia i.e air in biliary tract, shown as black area under liver  (Fig 2 )All other organs were normal and there was no evidence of malignancy 
No gall stones .Where did the gall stones go ? where from air came without any intervention or surgery ??? 

Fig 2 CT scan abdomen showing air in biliary tract Black shadow under liver above
Management :
The patient was managed with intravenous omeprazole 80 mg IV stat followed by an 8mg/hour infusion for 3 days. He was gradually started on liquid diet and oral esomeprazole 40mg twice daily, which was continued for another 3 months. The patient was continued on liquid diet, which was later advanced to soft diet with good tolerance. 
Repeat endoscopy (EGD) after 10 weeks showed no food residue and the pyloric channel this time permitted an adult diagnostic EGD scope. A catheter was introduced through the previously visualized opening of the choledochoduodenal fistula,(Fig 3) . 
Fig 3 Canulation done to through the opening in duodenum 
The cholangiogram showed dilated common bile duct and intrahepatic biliary ducts (Fig 4) without any filling defect.The gallbladder was distended without any filling defect. This opening only permitted access into the bile duct  confirming the fistulous tract between gall bladder and duodenum. 
Fig 4 Cholangiogram obtained and shows the biliary tract .
So the  gallstones had passed from gall bladder  into duodenum through this  fistulous tract . 
In 1896 Léon Bouveret described the first case of gastric outlet obstruction like this due to migration of gallstones and later number of cases were reported in the literature  .
          The clinical course of acute gastric outlet obstruction, presence of choledochoduodenal fistula, and resolution of symptoms   named after Bouveret  is   called  Bouveret’s syndrome.  

Message :
Bouveret’s syndrome should be suspected in old debilitated persons with de-novo pneumobilia. Management is surgical or endoscopic . Spontaneous resolution of gastric outlet obstruction in a set of patients may be achieved by proton pump inhibitors without any endoscopic or surgical intervention.

Further reading : 

Bouveret’s Syndrome. Case Report and Literature Review