Bouveret sendromu: Mide çýkýþ yolu obstrüksiyonunda ölümcül bir tanýsal ikilem

Bilinen ek hastalýðý ve geçirilmiþ ameliyat öyküsü olmayan 54 yaþýnda kadýn hasta dört gündür devam eden bulantý ve kusma yakýnmasýyla acil servise baþvurdu. Fizik muayenede karýnda hassasiyet saptanmadý. Baþvurusunda yapýlan laboratuvar incelemelerinde yüksek kan þekeri, ketonüri, lökositoz, yüksek C-reaktif protein, gama-glutamil-transferaz, laktat dehidrogenaz ve total bilirubin saptandý. Hasta yeni baþlangýç diabetes mellitus tanýsýyla dahiliye servisine yatýrýldý ve rutin incelemelerine baþlandý. Devam eden bulantý ve kusma nedeniyle yapýlan gastroskopide iyileþmiþ duodenal ülser saptandý. Karýn ultrasonografisinde kolelityazis saptandý. Dahiliye servisinde incelemeleri devam etmekteyken hastanýn týbbi durumu giderek kötüleþti. Hipotansiyon, taþikardi, lökositoz ve akut böbrek yetersizliði geliþen hasta septik þok tanýsýyla yoðun bakým ünitesine alýnarak intravenöz dopamin infüzyonu baþlandý. Çekilen bilgisayarlý tomografide distal duodenumda sýkýþmýþ görünümde bir safra taþý saptandý. YBU’da vital bulgularý stabilize edilen hasta ameliyata alýndý. Laparotomiyi takiben Treitz ligamaný distalinde proksimal jejunumda safra taþý görüldü. Longitudinal enterotomi ile taþ çýkarýldý. Hasta tekrar YBU’ya alýndý. Ameliyat sonrasý beþinci günde drenleri alýnan hastanýn gastrointestinal fonksiyonlarý normale döndü. Takiplerinde bakteriyemi ve fungemiye sekonder sepsis geliþen hasta ameliyat sonrasý 19. günde kaybedildi.

Bouveret syndrome: A fatal diagnostic dilemma of gastric outlet obstruction

The patient presented in this study was a 54-year-old woman complaining of nausea and vomiting, onset preceding four days, with no significant past medical history and an unremarkable surgical history. The patient was afebrile and hypertensive. Physical examination revealed a non-tender abdomen, and initial laboratory evaluation revealed elevated blood glucose level, ketonuria, leukocytosis, elevated C-reactive protein, gamma glutamyl transferase, lactate dehydrogenase, and total bilirubin. The patient was admitted to the internal medicine ward due to new onset of diabetes mellitus. Due to persistent nausea and vomiting, gastroscopy revealed a healed duodenal ulcer, and abdominal ultrasonography revealed cholelithiasis. The medical condition of the patient deteriorated further in the internal medicine ward, with impending hypotension, tachycardia, leukocytosis, and acute renal failure, and she was admitted to the intensive care unit due to septic shock. A computerized tomography was obtained, which revealed an impacted gallstone in the distal duodenum. The patient was taken to the operating room. The gallstone was encountered in proximal jejunum immediately distal to the ligament of Treitz. A longitudinal enterotomy was made, and the stone was extracted. Her drains were cleared on postoperative day 5, and gastrointestinal function returned to normal. Unfortunately, the patient developed an overwhelming sepsis due to bacteremia and fungemia, and died on post-operative day 19.