1689 Managing Bouveret Syndrome in the Setting of Complex Foregut Anatomy: Impossible Is Nothing!

Abstract

INTRODUCTION: Bouveret syndrome is a rare complication of cholelithiasis. Traditional treatment has been surgical, but endoscopic therapy has emerged as an attractive option, especially in surgically unfit patients. CASE DESCRIPTION/METHODS: An 80-year-old female with history of coronary artery disease/CABG on Clopidogrel and COPD on home oxygen presented with severe right upper-quadrant abdominal pain and nausea for 3 days. WBC was 14,400 μ/L, afebrile, with stable vital signs. Liver tests were normal. Abdominal ultrasound showed cholelithiasis and an obstructive calcified shadow at the pylorus. CT abdomen revealed a dilated stomach, gallstones and a 3 cm gallstone in the duodenal bulb with entero-biliary fistula. Endoscopic treatment of Bouveret was planned. At endoscopy, an unexpected high-grade mid-esophageal stricture prevented passage of standard and ultra-thin gastroscopes. A 8 mm balloon dilation was performed causing a modest-sized mucosal rent. An ultrathin gastroscope (5.9 mm) was then passed through the esophageal stricture and to the duodenum. A large pigmented gallstone was encountered in the duodenal bulb with luminal occlusion. Saline solution was infused and electrohydraulic lithotripsy (EHL) was performed at escalating settings up to 100W/ 20 shots per activation. The stone was ultimately fragmented and luminal patency restored. An ulcer with a visible vessel was seen at anterior wall of duodenal bulb; brisk bleeding was noted and hemostasis was achieved with epinephrine spray and 18 W cautery using pediatric snare tip, due to limitations of a 2.0 mm endoscope channel. The entero-biliary fistula was cannulated with the ultrathin endoscope and an additional large pigmented stone was seen in the gallbladder. This was left undisturbed. The patient had an uneventful recovery and was discharged home on regular diet after 2 days. DISCUSSION: Endoscopic management of Bouveret syndrome is an effective intervention and should be preferred in patients with severe comorbidities. This case demonstrates how anatomic and device related challenges were overcome using an ultrathin gastroscope to manage Bouveret syndrome and luminal bleeding. An ultrathin endoscope successfully permitted performance of EHL, evaluation of cholecystoduodenal fistula and hemostasis to save the day in this complex clinical scenario. Watch the video: http://bit.ly/2XSIcxr.