Mechanical Lithotripsy: A Viable Modality for Endoscopic Gallstone Extraction in Bouveret Syndrome

Abstract

Introduction: The creation of a bilioenteric fistula is a very rare complication of cholelithiasis which affects less than 1% of patients. The passage of a large gallstone through a cholecystoduodenal fistula and the subsequent impaction in the duodenum causing gastric outlet obstruction, also known as Bouveret Syndrome, is an even rarer occurrence. Given the relatively high mortality of 12-33%, and risk of stone migration causing mechanical small bowel obstruction or other morbidities as high 60%, it is important to diagnose it early and remove the stone safely. This can be done endoscopically, especially in patients who may otherwise be high risk for invasive procedures. Case: Our patient was an 86 year old male patient with a past medical history significant for coronary artery disease and stage 3 colorectal cancer status post resection and chemo -radiation, presented from an outlying facility for intractable sharp abdominal worse postprandially, one week in duration, associated with early satiety, anorexia and 5lbs weight loss in one week. A CT at the outlying facility showed possible choledochoenteric fistula, and a distended stomach. An esophagogastroduodenoscopy (EGD) was performed revealing a large 2.5 - 3 cm stone lodged in the duodenal bulb. The stone was extracted in 2 pieces after mechanical lithotripsy was performed. The duodenum was then reexamined and a posterior wall duodenal bulb ulcer and fistula tract orifice was noted. Examination of the CBD using endoscopic ultrasound pneumobilia. Conclusion: Endoscopic management of Bouveret syndrome is can immediately help in alleviating the gastrointestinal symptoms suffered by patients. Mechanical lithotripsy is one of a number of endoscopic options that can be utilized, especially in stones that are otherwise too large for extraction.Figure 1Figure 2