Erodes and bleeds, fistulises and obstructs: Bouveret's syndrome

One of the rare complications of cholelithiasis is gallstone ileus which occurs in <5% of patients. Among them, <3% develop Bouveret's syndrome: gastric outlet obstruction by a large gallstone in the pylorus or duodenum. One large review of 128 patients showed it to present at a mean age of 74.1 +/- 11.1 years with a mean gallstone size of 4.6 +/- 1.5 cm, with nausea or vomiting in 86%, abdominal pain in 71% and haematemesis in 15%. The diagnosis is usually clear on oesophagogastroduodenoscopy or abdominal contrast-enhanced computed tomography. We present a case with massive upper gastrointestinal bleeding, due to erosion of a cystic artery pseudoaneurysm.