title: A challenging case of gastric outlet obstruction (Bouveret's syndrome): a case report.
abstract: BACKGROUND
  Bouveret's syndrome is a clinically distinct form of gallstone ileus caused by the formation of a fistula between the biliary tract and duodenum. This case reinforces the need for early recognition and treatment of Bouveret's syndrome, as it is associated with high morbidity and mortality rates.
  
  
  METHODS
  An 82-year-old Caucasian woman presented with signs and symptoms of small bowel obstruction. Her laboratory workup showed elevated alkaline phosphatase and amylase levels. Computed tomography of her abdomen revealed pneumobilia, a choledochoduodenal fistula and a gallstone obstructing her distal duodenum. The impacted gallstone could not be extracted endoscopically, so our patient underwent open enterolithotomy successfully. However, the postoperative course was complicated by myocardial infarction, respiratory failure and disseminated intravascular coagulation. She died 22 days after surgery, secondary to cardiopulmonary arrest.
  
  
  CONCLUSIONS
  This case clearly highlights the considerable morbidity and mortality associated with Bouveret's syndrome.
authors.affiliation: Department of General Internal Medicine, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite 933W, Pittsburgh, PA 15213, USA. gajendranm@upmc.edu.
authors.forename: Mahesh
authors.initials: M
authors.lastname: Gajendran
authors.forename: Thiruvengadam
authors.initials: T
authors.lastname: Muniraj
authors.forename: Andres
authors.initials: A
authors.lastname: Gelrud