A Typical Case of Bouveret’s Syndrome, or Not?

A 68-year-old obese woman (BMI 57kg/m2) presented with continuous abdominal pain and extensive vomiting since ve days. Physical examination revealed sparse peristaltic sounds, abdominal tenderness but no muscular defense. Laboratory examination showed increased C-reactive protein (79 mg/L) and leucocytosis (17.5 x109/L). Liver function tests were normal. CT scan demonstrated an air-fluid level inside the gallbladder (Fig. 1, axial MDCT slice in late portal-venous phase) and a thickened gallbladder wall, which was not sharply delineated from the stomach wall (Fig. 2, coronal MDCT slice). ese ndings suggested stulisation from the gallbladder to the duodenum or stomach, presumably by a gallstone. Bowel obstruction could not be objectivated. Under the diagnosis of “Bouveret’s syndrome”, a gastroduodenoscopy was performed in order to con rm the diagnosis and clear the duodenum from possible gallstones. Surprisingly, gastroduodenoscopy did not show gallstones, but revealed a sharp piece of plastic, stuck in the antrum of the stomach. e prepyloric gastric wall showed edema and puss excretion from the perforation site (Fig. 3). e foreign body could be removed successfully. A er one month of follow-up, the patient was completely recovered. She mentioned that she had probably ingested a plastic wrapping of a deep frozen pizza. Ingestion of a foreign body does not cause any symptoms in 80-90% of the cases. When symptoms arise they are usually secondary to obstruction or in ammation. Gastrointestinal perforation by ingested foreign bodies occurs in less than 1% of patients. Diagnosis is di cult due to multiple reasons. Patients are o en unaware of ingestion of a foreign body and the clinical IMAGE OF THE ISSUE