<Case Report>Duodenal Obstruction by Gallstone : Case Report of Bouveret's Syndrome

Abstract

Bouveret's syndrome involves gastric outlet obstruction by gallstone. Herein we describe an unusual case of duodenal bulb obstruction by gallstone. An 80－year-old woman was hospitalized with a fifteen-day history of vomiting. Computed tomography (CT) showed pneumobilia and a round calcified mass in the second portion of the duodenum. Upper gastrointestinal tract series demonstrated the same sized oval radiolucency between the bulbus and the second po口ion of the duodenum. Endscopic examination revealed a round black mass in the second portion of the duodenum, totally occupying the lumen. Endoscopic removal and destruction of the gallstone was attempted using a dye-laser, but the stone was too hard to crush. Eventually surgical enterolithotomy was successfully performed without cholecystectomy or closure of the fistula. Improved preoperative systemic management and prompt examination allowed earlier surgical intervention and reduced the morbidity. Surgical approach whethere fistula closure should be performed remains controversial.

Bouveret's 症候群は胆石による胃内容排池障害を主症状とする症候群である. われわれはここに胆石による十二指腸球部閉鎖をきたした症例を報告する. 症例は80歳の女性で, 15日間持続する幅吐を主訴に入院した. CTでは胆管内空気像と十二指腸下行脚内に球形の石灰化像を認めた. 上部消化管透視では十二指腸球部と下行脚の聞に同じ大きさの卵円形の陰影欠損を認めた. 上部消化管内視鏡では十二指腸下行脚を完全に占める黒色の結石を認めた. ダイレーザーを用いた内視鏡的破砕を試みたが結石が固すぎて破砕できなかったため, 腸管切開により結石を除去した. 胆嚢摘出術と痩孔閉鎖は行わなかった. 術前の全身管理の進歩と迅速な術前検査により本症候群では, 早期の外科的治療が可能となり, 死亡率は低下した. 瘻孔閉鎖を一期的に施行するかどうかは議論の残るところである.