S2772 Bouveret Syndrome: Using Electrohydraulic Lithotripsy to Clear the Way

Abstract

INTRODUCTION: Bouveret syndrome is a rare form of gallstone ileus that occurs by passage of a gallstone through an acquired cholecystoduodenal or cholecystogastric fistula into the enteric lumen leading to gastric outlet obstruction. It is seen in less than 0.5% of patients with cholelithiasis and represents 1-3% of all gallstone ileus cases. Although several cases of Bouveret Syndrome exist within the literature, we describe a rare case using electrohydraulic lithotripsy (EHL) as a successful treatment option. CASE DESCRIPTION/METHODS: A 67-year-old man with past medical history significant for metastatic melanoma and history of locally advanced tonsillar carcinoma presented to the hospital with acute onset nausea, vomiting, and abdominal pain for 2-day duration. On physical exam, he was afebrile and hemodynamically stable. His abdomen was mildly distended and tender without guarding. Lab assessment was unremarkable. An abdominal computed tomography (CT) revealed a cholecystoduodenal fistula and an obstructing calcified stone in the duodenum with pneumobilia (Figure 1). After a discussion with surgery, the patient was taken for an esophagogastroduodenoscopy (EGD) revealing a large, approximately 3 cm stone completely occluding the duodenal sweep (Figure 2). EHL under water immersion was used to break up the impacted stone. Small pieces were continuously removed from the duodenal lumen with a tripod grasper and placed in the stomach where they were further fragmented. Following gallstone clearance, a large ulcer and cholecystoduodenal fistulous tract was present in the duodenal sweep (Figure 3). The patient did well after the procedure and discharged home without complications. DISCUSSION: Being that Bouveret syndrome is rare and symptoms are nonspecific, a high clinical suspicion needs to exist to make an accurate diagnosis. Imaging findings suggestive of Bouveret syndrome include a dilated stomach, pneumobilia, and a radio-opaque shadow suggesting a gallstone. These findings make up Rigler's triad. Treatment options include surgery and endoscopic interventions. Multiple endoscopic modalities are utilized for the treatment of this syndrome including removal baskets, mechanical lithotripsy, electrohydraulic lithotripsy, and laser lithotripsy. EHL is commonly used, but only successful in 10 % of cases. Although reports of endoscopic success are poor in the literature it should be attempted to decrease the morbidity and mortality associated with surgery that can be as high as 25%.Figure 1Figure 2Figure 3