Bouveret syndrome, a rare clinical presentation of abdominal pain in a patient with diabetic ketoacidosis: A case report.

Abstract

Introduction and Objectives: To present a 70-year-old female with type 2 diabetes and a history of multiple episodes of cholecystitis within Bouveret's Syndrome. Materials and Patients: 70-year-old female with type 2 diabetes and a history of multiple episodes of cholecystitis refusing surgical treatment. She was admitted to the emergency department due to a clinical picture of 10 days of evolution characterized by severe abdominal pain localized in the right hypochondrium that was exacerbated after food intake. Symptoms included nausea, vomiting and malaise. Physical examination revealed a Glasgow score of 15 points, cardiopulmonary normal, abdomen tenderness on palpation, increased peristaltic sounds, and negative Murphy and Blumberg signs with no evidence of peritoneal irritation. Rest normal. Leukocytes 17.1, neutrophils 15.4, hemoglobin 12.3, platelets 45.000, glucose 614, BUN 54, urea 117, creatinine 3.3, AST 82, ALT 52, LDH 264, alkaline phosphatase 155, total bilirubin 0.56, albumin 1.9, gamma glutamyl transpeptidase 99, serum electrolytes normal. Urine tests with ketones and arterial blood gases with metabolic acidosis. Management for diabetic ketoacidosis was started with poor clinical progression and, worsening of abdominal pain and absence of bowel movements. Abdominal ultrasound showed a hepatic image in segment IVa with defined borders; it measured 47 × 38 millimeters, suggestive of a biloma. The gallbladder had heterogeneous content with multiple stones and acute lithiasic cholecystitis. The CT identified a stone in the first and second portions of the duodenum, biliary ilium and a cholecystoduodenal fistula. Results: Bouveret syndrome was diagnosed by performing a duodenoscopy in which a fistulous orifice with bile outlet was observed, posteriorly removing the stone with no complications during the procedure. Image-guided drainage of the biloma was performed with a multipurpose catheter placement with total resolution. Diabetic ketoacidosis was treated under usual measures, observing a general and important improvement in the patient. Conclusions: Bouveret syndrome is a rare clinical entity and its simultaneous appearance with an acute episode of diabetic ketoacidosis is rarely described in the literature. Only 6% of patients with cholecystoenteric fistulas develop a clinical picture of intestinal obstruction, with duodenal obstruction being the less frequent (<5%).