S2515 Where Did You Come From, Where Did You Go? A Tall Tale of Bouveret’s Travels

Abstract

Introduction: Bouveret syndrome (BS) refers to a gastric outlet obstruction (GOO) secondary to an impacted gallstone in the pylorus or proximal duodenum. Our case describes BS with migrated gallstone to the distal jejunum causing a small bowel obstruction (SBO) successfully treated with prompt interventional endoscopic (IE) intervention. Case Description/Methods: 86-year-old male presented with nausea, vomiting, and hiccups for the past 3weeks. CT revealed dilated stomach, possible GOO. Urgent endoscopy revealed dilated stomach, 1 large completely obstructing, non-bleeding cratered duodenal ulcer, and large impacted gallstone at the distal duodenal bulb. IE consultation prompted repeat EGD 3 days later showed 1cm fistula in the duodenal bulb to the gallbladder remnant, no evidence of residual gallstone in the bulb, second and third portion of duodenum were normal. CT showed SBO with a transition point in left hemiabdomen. Subsequent double-balloon enteroscopy identified 4cm gallstone in distal jejunum causing SBO. Electrohydraulic lithotripsy successfully fragmented the stone (Figure 1). Patient advanced diet and fully recovered. Discussion: Bouveret's syndrome, described in 1770, represents 2–3% of all gallstone-related GOO and 1–4% of all SBOs. Morbidity and mortality rates, about 60% and 30% respectively, are reported in cases where a patient is a nonsurgical candidate due to comorbidities. Large stones typically require surgical intervention and have high mortality (12-27%). Our case describes treatment success with IE.Figure 1.: First EGD: A, severe LA Grade D esophagitis, B-H shows large completely obstructing, non-bleeding cratered duodenal ulcer 30mm, and large gallstone impacted at the distal end of duodenal bulb. Second EGD: I-K Duodenal Fistula, L-N Fistulous connection to Gallbladder Double Balloon Enteroscopy: O, Large impacted gallstone in distal jejunum. P-U electrohydraulic lithotrpsy performed on impacted gallstone, U-V Clearance of broken particles with aggressive flushing, W-Y Fluoroscopic images showing radiolucent defect, Z Resolution of defect on fluoroscopy.