Clinical Vignettes/Case Reports - Endoscopy.

Abstract

Bouveret syndrome, a gastroduodenal obstruction caused by an impacted gallstone through a cholecystoduodenal or cholecystogastric fistula, was first described in France in 1896 by Léon Bouveret. The treatment is primarily surgical. Endoscopic management via electrohydraulic lithotripsy (EHL) is rarely reported in the literature. An 84-year-old woman was admitted to the hospital with several days of abdominal pain, nausea, bilious emesis, and inability to tolerate oral intake. On physical exam, she had a distended and tympanitic abdomen with epigastric and periumbilical tenderness. Nasogastric tube decompression removed 1.5L of bilious fluid. Laboratory studies, including a CMP and CBC, were normal. Computed tomography of the abdomen and pelvis demonstrated a dilated stomach and proximal duodenum with a fluid filled level within the duodenal bulb. A non-enhancing, elliptical 4.8 x 2.8 x 2.9cm mixed low and high attenuation structure containing trapped gas was noted in the third segment of the duodenum. A 3 x 3cm deformity was seen in the duodenal bulb. Minimal contrast passed distal to the obstruction. The patient underwent an EGD, which revealed a large cholecystoduodenal fistulous tract in the duodenal bulb and a large 5cm impacted gallstone in the third portion of the duodenum just distal to a normal ampulla. As the patient had significant cardiac co-morbidities, she was deemed high risk for surgical intervention. Thus, she underwent two sessions of enteroscopy with EHL (power 100, shots 20 uptitrated to 30) with saline submersion, which successfully fragmented the gallstone into numerable sub-centimeter particles. Following the second EHL session, lumen patency was reestablished and a pediatric colonoscope was able to easily traverse the previous area of obstruction into the proximal portion of the jejunum. After a few days of observation and advancement of diet, the patient was discharged home. Bouveret syndrome, also known as gallstone ileus, is a rare complication of gallstone disease. It is more commonly observed in women and in the geriatric population. Patients often present with signs and symptoms of gastric outlet obstruction. Imaging and/or endoscopy confirm the diagnosis in less than 70% of cases. This case illustrates the ability of endoscopic EHL to safely and successfully fragment a large gallstone in order to relieve the duodenal obstruction and offer a minimally invasive alternative to traditional surgery.