Multiple Cholecystoenteric Fistulae With Bouveret Syndrome and Acute Pancreatitis: A Rare Combination

Multiple cholecystoenteric fistulae, Bouveret syndrome (a form of gallstone ileus), and acute pancreatitis occurring together is very rare. Diagnosis is seldom clinical and is mostly based on computerised tomography (CT) or magnetic resonance imaging (MRI). Endoscopy and minimally invasive surgery have revolutionised the treatment of Bouveret syndrome and cholecystoenteric fistula, respectively, over the last two decades. Laparoscopic repair of cholecystoenteric fistula followed by cholecystectomy is successful on a consistent basis with skilled laparoscopic suturing and advanced laparoscopy. In patients with Bouveret syndrome, when the stone is <4cm and is in the proximal duodenum, it is usually amenable for endoscopic extraction with snares, nets, forceps and lithotripsy. When endoscopy is unavailable or fails, laparoscopic surgery is suitable for these patients. However, stones >4 cm, located in the distal duodenum, multiple fistulae, and associated acute pancreatitis may necessitate open surgery. We present here a case of a 65-year-old Indian female with multiple cholecystoenteric fistulae and Bouveret syndrome with acute pancreatitis with a 6.5 cm gallstone diagnosed on CT scan and MRI and treated successfully by open surgery. We also review the current literature on the management of this complex problem.