A woman in her early 90s presented to the acute surgical take with a 3-day history of worsening reflux, vomiting, epigastric pain and constipation. Subsequent imaging demonstrated two large, impacted gallstones in the pylorus and proximal jejunum secondary to a cholecystoduodenal fistula. A diagnosis of Bouveret syndrome was made, and endoscopic attempts to break down and remove the stones were unsuccessful. The stones were left in the stomach, with a pigtail stent placed through the fistula between the stomach and gallbladder to prevent the stones impacting again and to allow adequate drainage of the gallbladder to prevent further flare-ups. Due to the patient's comorbidities, it was decided to leave the stent in situ long term as opposed to surgical management. This has shown to be successful in follow-up. Our case highlights that Bouveret syndrome can potentially be managed conservatively long term in patients deemed unfit for major surgical intervention.

To investigate and summarise the current evidence surrounding management of Bouveret's syndrome (BS).

A MEDLINE search was performed for the BS. The search was conducted independently by two clinicians (Yahya AL-Habbal and Matthew Ng) in April 2016. A case of BS is also described.

A total of 315 articles, published from 1967 to 2016, were found. For a clinically meaningful clinical review, articles published before 01/01/1990 and were excluded, leaving 235 unique articles to review. Twenty-seven articles were not available (neither by direct communication nor through inter-library transfer). These were also excluded. The final number of articles reviewed was 208. There were 161 case reports, 13 reviews, 23 images (radiological and clinical images), and 11 letters to editor. Female to male ratio was 1.82. Mean age was 74 years. Treatment modalities included laparotomy in the majority of cases, laparoscopic surgery, endoscopic surgery and shockwave lithotripsy.

There is limited evidence in the literature about the appropriate approach. We suggest an algorithm for management of BS.

The aim of the study was to characterize the clinical presentation, evaluation, and therapy of Bouveret's syndrome, by comprehensively reviewing all the identified previously reported cases, to facilitate early diagnosis and thereby to improve the prognosis.

Relevant articles were identified by MEDLINE computerized searches, by consultation with all available reference books, and by review of the first author's teaching files. A new case in which the diagnosis of Bouveret's syndrome was missed at esophagogastroduodenoscopy (EGD)--despite endoscopic findings of gastric outlet obstruction caused by a hard, nonfleshy, and convex pyloric mass--prompted this review.

Review of 128 reported cases identified syndromic characteristics. Patients on average were 74.1 +/- 11.1 (SD) yr old. The female-to-male sex ratio was 1.86. Prominent symptoms were nausea and vomiting in 87%, abdominal pain in 71%, hematemesis in 15%, recent weight loss in 14%, and anorexia in 13% of patients. Prominent signs were abdominal tenderness in 44%, signs of dehydration in 31%, and abdominal distention in 26% of patients. Endoscopy revealed gastroduodenal obstruction in nearly all cases, but identified the obstructing stone in only 69%. Abdominal ultrasound or computerized tomography was diagnostic in about 60% of cases.

The following endoscopic findings are suggestive of Bouveret's syndrome: a dilated stomach containing old digested food from gastrointestinal obstruction together with a hard and nonfleshy mass at the obstruction. These endoscopic findings, in the setting of the currently reported characteristic epidemiologic and clinical findings, should strongly suggest this syndrome. Abdominal ultrasound or computerized tomography is recommended to confirm and extend the endoscopic diagnosis.