Impacted Gallstone Research Articles

Preoperative predictors of difficult early laparoscopic cholecystectomy among patients with acute calculous cholecystitis in Egypt

BackgroundEarly laparoscopic cholecystectomy (ELC) in the setting of acute calculous cholecystitis (ACC) requires to be performed by highly-skilled surgeons to avoid complications. The purpose of this study is to identify preoperative factors that would predict difficult ELC among patients with ACC prior to proceeding with surgery.MethodsWe retrospectively reviewed all patients who received ELC within 10 days from the onset of symptoms of ACC between August 1, 2018, and December 31, 2022. They were divided into 2 groups according to the difficulty of surgery.Results149 patients with ACC received ELC during the study period. ELC was considered difficult in 52 patients (35%). Five preoperative factors were identified as significant predictors of difficult ELC (DELC) on multivariate analysis: duration of acute attack ≥ 4 days from the onset of symptoms till surgery (OR 34.4, P < 0.001), ultrasound showing largest gallstone size > 20 mm (OR 20.2, P = 0.029), ultrasound showing gallstone impaction in Hartmann’s pouch (OR 7.2, P = 0.017), history of prior episode(s) of acute attack (OR 6.8, P = 0.048), and diabetes mellitus (OR 5.8, P = 0.046).ConclusionCareful preoperative assessment of patients with ACC is crucial among junior surgeons with limited surgical expertise prior to proceeding with ELC to identify those at risk of DELC to potentially reduce postoperative morbidity and mortality. If encountered, a management plan should be made, and surgery should proceed only upon confirming the availability of experienced surgeons in the field of biliary and laparoscopic surgery to supervise or assist in the procedure. Alternatively, such group of patients should rather be transferred to more advanced surgical centers which offer higher level of care to maintain patient safety and optimal surgical outcomes. More importantly, bail-out procedures should always be resorted to whenever DELC is encountered intraoperatively to prevent further surgical damage.

ThP5.15 - "Unusual Impaction: A Rare Case of Gallstone Ileus''

Abstract Introduction Gallstone-related mechanical gastrointestinal tract obstruction is infrequent, manifesting in only 0.3%-0.5% of cholelithiasis cases. Typically, stones exceeding 2 cm find themselves lodged in the terminal ileum. However, in Bouveret's syndrome which is observed in 1 to 3% of instances the impaction occurs in the duodenum causing gastric outlet obstruction. The epidemiology and prevalence of gallstone impaction in the proximal jejunum remain inadequately documented, making this a rare case. Case Report An 83-year-old patient with known cholelithiasis and choledocholithiasis presented with acute abdominal pain and vomiting a week after undergoing ERCP, sphincterotomy and partial duct clearance. The presence of repeated bilious vomiting prompted investigation with abdominal CT scan. This revealed an approximately 4.5 cm gallstone impacted in the proximal jejunum, prompting emergency laparotomy which confirmed that the stone was impacted 10-15 cm from the dudeno-jejunal junction. Jejunotomy, stone extraction with primary closure was performed. Post-operative recovery was uneventful. Conclusion This case demonstrates gallstone impaction in the proximal jejunum causing bowel obstruction and necessitating emergency intervention. Timely diagnosis and prompt surgical intervention led to a successful outcome. The case highlights the need for awareness and consideration of the entire spectrum of possible gallstone-related complications in the acutely presenting patient with gall stones.

WP4.16 - Gallstone ileus as an infrequent cause of bowel obstruction- a review of small cohort

Abstract Introduction It is uncommon cause of small bowel obstruction, presents 1 – 5% of adult population. It is a rare complication of chronic cholecystitis which lead to cholecysto-enteric fistula and impaction of gall stone in GI tract leading to mechanical bowel obstruction. Our aim is to report the natural history and management of this condition in District Hospital. Method Retrospective 10 years of data was collected with CT findings of intestinal obstruction with gall stone ileus. It included 10 patients over 10 years whose medical records were evaluated retrospectively. Results Majority of patients were female (90%, n:9) with mean age of 81.6 years (range 61-96) although 90% of population were above 70 years. Presenting complaints were mostly pain and vomiting. Onset of symptoms between 2- 7 days. The site of obstruction was mostly ileum (n=9) with exception of one case in sigmoid proximal to stricture and size of stone was ranging ffrom2.5 to 4 cm, moreover most of the patients had previous history of gall stone (n=7) with one post cholecystectomy status. During routine investigations 50 % of patients had deranged LFT &amp;AKI and 50-60% had raised inflammatory markers (WBC,CRP).Intervention as Enterolithotomy was the preferred approach (n=8,2 lap ,7 open) and non operative management was performed in two cases.The mean post op length of stay were 10 days in open and 5 days in Lap respectively. Conclusions Elderly female patients are more prone to have gallstone ileus particularly with a past medical history of gall stone and the preferred management option is Enterolithotomy which could be open or laparoscopic depending on expertise of the Surgeon.

EP23 - A rare case of “Gastric Outlet Obstruction (GOO) Secondary to Hydrops of Gallbladder” caused by recurrent acalculous cholecystitis: a variant of Bouveret’s Syndrome -a rare case and review of literature

Abstract We present an extremely rare case of gastric outlet obstruction (GOO) in a young male attributed to hydrops of the gallbladder resulting from recurrent episodes of acute acalculous cholecystitis. Remarkably, approximately one and half years prior to this presentation, the patient was diagnosed with confirmed acute acalculous cholecystitis and had tested positive for Covid 19, despite exhibiting no respiratory symptoms. While it is established that Patients with acute acalculous cholecystitis can develop gallbladder mucoceles due to the mechanism akin to mechanical cystic duct obstructions. This functional condition leads to a non-emptying, distended gallbladder where biliary mucus replaces bile salts (1). Conventionally, hydrops of the gallbladder is associated with prolonged blockage of the cystic duct, often caused by an impacted gallstone in neck / cystic duct or a stricture in cystic duct. Bouveret’s Syndrome, characterized by GOO results from the impaction of a large gallstone in the duodenum or pyloric channel, typically secondary to a cholecystoenteric fistula (2),is a recognized rare entity. However, our case stands apart as it elucidates an infrequently reported cause of GOO- hydrops of gall bladder inducing extrinsic compression of the duodenum / pylorus and this case also emphasizes the distinction from Bouveret’s syndrome. This case underscores the importance of considering unusual etiologies in the diagnosis of GOO and emphasizes the need for timely recognition and intervention in such rare instances to ensure optimal patient outcomes. Additionally, we provide a comprehensive review of existing literature, highlighting the scarcity of reported cases with such relevant presentations.

Gallstone Ileus as an Infrequent Cause of Bowel Obstruction: A Review of Small Cohort.

Introduction Gallstone ileus is an uncommon cause of small bowel obstruction; it is a rare complication of calculus chronic cholecystitis which leads to cholecystoenteric fistula and impaction of gallstone in the gastrointestinal tract leading to mechanical bowel obstruction. Our aim is to report the natural history and management of this rare condition in a teaching hospital. Materials and methods It is a retrospective study, where 10 years of data related to the management of intestinal obstruction secondary to gallstone ileus was collected. The cohort included 10 patients, whose demographic data, clinical findings, and management outcomes were evaluated. Results Majority of patients were female (90%, n=9) with a median of 83 years (range 61-96) although 90% of the population were above 70 years. Presenting complaints were mostly pain and vomiting. The onset of symptoms was between two and seven days.The site of obstruction was mostly the ileum (n=9) with the exception of one case in the sigmoid proximal to a benign stricture, and the size of the stone ranged from 2.5 to 4 cm. Moreover, most of the patients had a previous history of gallstone (n=7) with one post-cholecystectomy status. The laboratory investigations in 50% of patients had deranged liver function test (LFT) and acute kidney injury (AKI), and 60% had raised inflammatory markers, namely, white blood cells (WBC) and C-reactive protein (CRP). Intervention as enterolithotomy was the preferred approach (n=8 (two laparoscopic, six open surgery)), and two patients were managed conservatively. The mean postoperative length of stay was 10 days in the open approach and five days in the laparoscopic approach, respectively. Conclusions Elderly female patients are more prone to have gallstone ileus particularly with a past medical history of gallstones, and the preferred management option is enterolithotomy which could be open or laparoscopic depending on the expertise of the surgeon.

Gallstone Ileus: Unfortunate Encounter

Gallstone disease is a common burden that affect worldwide that carry broad spectrum of its complications and severities. Gallstone ileus (GSI) remained the rare complication that arise form gallstone disease that mainly affected the elderly population. The mainstay of treatment for GSI is to relieve the small bowel obstruction by extraction of the impacted gallstone. Surgical options for GSI remained the long-standing arguments involve single-staged procedure (enterolithotomy, cholecystectomy and fistula repair) or twostaged procedure (enterolithotomy alone, and cholecystectomy with fistula repair later). We reported a case of a 76-year-old male who presented with symptoms of small bowel obstruction and computed tomography (CT) of abdomen confirmed the presence of calcified lesion at ileum with pneumobilia which was successfully managed with two-staged procedure.&#x0D; Bangladesh Journal of Medical Science Vol. 23 No. 01 January’24 Page : 272-275

Post-laparoscopic cholecystectomy pancreatitis

Laparoscopic cholecystectomy is one of the commonest operations performed on the biliary system. Acute pancreatitis following Lap-chole is quite uncommon. Whether pancreatitis is a complication or a sequalae to surgical treatment of gall stone disease continues to be a debatable issue. A 37-year-old lady underwent laparoscopic cholecystectomy for incidentally diagnosed gall stones. Early post-operative course was uneventful. The patient presented 3 weeks after surgery with severe excruciating abdominal pain and was diagnosed as acute pancreatitis by ultrasound evaluation. Liver function tests were altered with raised bilirubin, serum lipase and amylase. MRCP revealed a normal biliary tract. Pancreas showed changes of acute interstitial pancreatitis. Patient responded to conservative line of treatment. Acute pancreatitis could be a known complication following laparoscopic cholecystectomy. What causes pancreatitis continues to be a matter for debate. MRCP is the investigation of choice. Interventional endoscopy (ERCP) is indicated in cases of impacted gallstone in the CBD. While if the CBD is clear of stones, aggressive conservative management will suffice.

Gallstones ileus in young patient with incidental finding a small bowl carcinoid tumour

Gallstone ileus in young patient with incidental finding carcinoid of small bowel identified during exploration for proximal stones, both pathologies have no known pathological reasons to be associated with each other. We present a case of a 45-year-old male who presented with small bowel obstruction as an emergency. At laparotomy we found gall stone impacted in mid ileum and during exploration to exclude multiple proximal stones, small carcinoid identified in mid jejunum. Segmental small bowel resection was performed without disturbing the biliary pathology. Gallstone ileus may manifest in the younger population, and in the course of searching the small bowel to eliminate the presence of multiple stones proximal to the site of the impacted gallstone ileus other pathology may detected for which we incidentally identified asymptomatic carcinoid such case has never been reported before. Importance of a thorough laparotomy is emphasized.

Mirizzi Syndrome-The Past, Present, and Future.

Mirizzi syndrome is a complication of gallstone disease caused by an impacted gallstone in the infundibulum of the gallbladder or within the cystic duct, causing chronic inflammation and extrinsic compression of the common hepatic duct or common bile duct. Eventually, mucosal ulceration occurs and progresses to cholecystobiliary fistulation. Numerous systems exist to classify Mirizzi syndrome, with the Csendes classification widely adopted. It describes five types of Mirizzi syndrome according to the presence of a cholecystobiliary fistula and its corresponding severity, and whether a cholecystoenteric fistula is present. The clinical presentation of Mirizzi syndrome is non-specific, and patients typically have a longstanding history of gallstones. It commonly presents with obstructive jaundice, and can mimic gallbladder, biliary, or pancreatic malignancy. Achieving a preoperative diagnosis guides surgical planning and improves treatment outcomes. However, a significant proportion of cases of Mirizzi syndrome are diagnosed intraoperatively, and the presence of dense adhesions and distorted anatomy at Calot's triangle increases the risk of bile duct injury. Cholecystectomy remains the mainstay of treatment for Mirizzi syndrome, and laparoscopic cholecystectomy is increasingly becoming a viable option, especially for less severe stages of cholecystobiliary fistula. Subtotal cholecystectomy is feasible if total cholecystectomy cannot be performed safely. Additional procedures may be required, such as common bile duct exploration, choledochoplasty, and bilioenteric anastomosis. Conclusions: There is currently no consensus for the management of Mirizzi syndrome, as the management options depend on the extent of surgical pathology and availability of surgical expertise. Multidisciplinary collaboration is important to achieve diagnostic accuracy and guide treatment planning to ensure good clinical outcomes.

A Rare Presentation of Intestinal Obstruction: Gall Stone Ileus

Gallstone ileus is a mechanical intestinal obstruction due to gallstone impaction within the gastrointestinal tract.1 It is an unusual complication of cholelithiasis, occurring in fewer than 0.5 percent of patients.2 Typically as a result of the formation of cholecysto-duodenal fistula, surgical removal of the gallstone is the mainstay of treatment in order to relieve the intestinal obstruction. Objective: To know about this rare diagnosis so that one can keep it as a differential diagnosis for intestinal obstruction and thus manage accourdingly. Keywords: Intestinal obstruction, Gallstone ileus, Bouveret’s syndrome, Cholecystoduodenal fistula, Bilio-enteric fistula.

Obstructive quandary: A comprehensive case report of gallstone ileus

Gallstone ileus (GI), an infrequent but complex complication of cholelithiasis, poses a multifaceted challenge in the field of general surgery. We present a case report of a 99-year-old male with GI, characterized by mechanical obstruction within the small bowel due to gallstone impaction, and offer a review of the literature on this subject. GI emerges as a late-stage complication of gallstone disease, primarily manifesting in elderly individuals, with a higher incidence among women. The condition is driven by the migration of gallstones through fistulas, most commonly forming connections with the small bowel. Diagnosis is intricate due to nonspecific clinical symptoms, often requiring imaging modalities like abdominal CT scans. Treatment necessitates surgical intervention, addressing both intestinal obstruction and cholecystoenteric fistula management. The approach, whether one-stage or sequential, is guided by individual patient characteristics.

Gallstone Ileus: A Stone In The Way

Gallstone ileus, a rare complication of cholelithiasis, is caused by an impaction of gallstones within the gastrointestinal tract leading to mechanical intestinal obstruction. Here in, we describe a case of gallstone ileus in a 62-year-old woman successfully treated with enterolithotomy. The patient was discharged home after an uneventful post-operative period. Gallstone ileus is an uncommon complication of gallstones and a rare cause of intestinal obstruction, with often delayed presentation and non-specific symptoms. The preferred approach is enterolithotomy. Elective cholecystectomy after the acute episode is controversial.

Bouveret Syndrome: Large Gallstone Causing Duodenal Obstruction

Introduction: Bouveret syndrome consists of a gastric outlet obstruction due to the impaction of a gallstone in the duodenal bulb after it migrates through a cholecystoduodenal fistula. This syndrome represents only 1% to 3% of all cases of gallstone ileus, being more frequent in women and in the elderly. Case report: 86-year-old patient with diffuse colicky abdominal pain, diarrhea, and yellowish vomiting. The imaging tests revealed significant duodenal dilation with the presence of a cholecystoduodenal fistula and a large rounded impacted gallstone. The patient underwent emergency surgery through an enterotomy with removal of the gallstone and primary closure. Discussion: Bouveret's syndrome is a rare gallstone ileus condition that implies significant morbidity and mortality and often occurs in the elderly with significant comorbidities. Individual diagnosis and treatment strategies are required for optimal management and results, being endoscopic treatment or open surgery the two most suitable available options. Conclusions: Bouveret syndrome is a life-threatening condition with gastric outlet obstruction caused by large gallstones. CT and MRI scans are useful for diagnosis. Although in some cases percutaneous and endoscopic treatments can be successful as first-line treatment, most patients require surgery, however, the decision must be taken individually.

OPTION TO FINISH SURGICAL OPERATION IN PATIENT WITH MIRIZZI SYNDROME

Mirizzi syndrome is a rare condition caused by the obstruction of the common bile duct or common hepatic duct by external compression from multiple impacted gallstones or a single large impacted gallstone in Hartman's pouch.&#x0D; Mirizzi syndrome is one of the most severe complications of cholelithiasis and the most complex pathological process in biliary surgery in general. Mirizzi syndrome is a compression of the common hepatic bile duct by a gallstone, which is usually located in Hartmann's pouch, and the subsequent formation of a cholecysto-choledochial fistula. This syndrome is named after the Argentinean surgeon, who described the obstruction of the common bile duct or common hepatic duct by external compression from multiple impacted gallstones or a single large impacted gallstone; the phenomenon was observed during the intraoperative cholangiography. Mirizzi syndrome is conventionally classified into four types: type I is described as the compression of the common hepatic duct by a stone from the gallbladder side; type II is characterized by the presence of a cholecysto-choledochial fistula that involves one-third of the choledochus diameter; type III is similar to type II but involves two-thirds of the choledochus diameter; type IV represents complete destruction of the wall of the common hepatic duct, resulting in the formation of a complete biliobiliary fistula. Mirizzi syndrome does not have its own specific clinical manifestations, and screening methods like abdominal ultrasonography may not always provide a clear indication of this pathology. In such cases, diagnostic procedures such as endoscopic retrograde cholangiopancreatography (ERCP) and magnetic resonance imaging (MRI) of the biliary tract can help establish an accurate diagnosis and determine the appropriate surgical approach prior to the operation. The article presents the clinical case of a 29-year-old patient M., who was admitted to the surgical department. Although there was a discrepancy between the findings of magnetic resonance imaging of the biliary tract and the identified anatomical changes during diagnostic laparoscopy of the hepatobiliary tract, the surgeons' expertise and adherence to safe cholecystectomy guidelines enabled the successful completion of the operation using a minimally invasive approach.

Defining Critical View of Safety During Laparoscopic Cholecystectomy: The Preoperative Predictors of Failure.

Background Defining critical view of safety (CVS) is one of the most crucial steps during laparoscopic cholecystectomy (LC). This study aimed to determine the preoperative predictors of failure to achieve CVS during LC. Methods All patients undergoing LC from December 2020 to July 2022 were prospectively included. Results There were 180 females and 93 males. CVS was achieved during LC in 238 (87.2%) patients. Conversion to open surgery was performed for 11 patients. Bile leak occurred in three patients which resolved spontaneously. No patient developed bile duct injury. On univariate analysis, age, male sex, American Society of Anaesthesiologists (ASA) grading, Murphy's sign, emergency surgery, neutrophil percentage, lymphocyte percentage, gallbladder wall thickness > 3mm, and impacted gallstone on abdominal ultrasound were predictors of failure to achieve CVS. On multivariate analysis, neutrophil and lymphocyte percentages were independent predictors of failure to achieve CVS. Patients in whom CVS could not be achieved had significantly longer operative time, higher blood loss, complications, and hospital stays. Discussion Inability to achieve CVS during LC can be predicted preoperatively using various parameters including neutrophil and lymphocyte percentages. Such cases must be operated by senior surgeons or referred to experienced general or hepatobiliary surgeons for cholecystectomy to avoid bile duct injury. The proposed algorithm can help in intraoperative decision-making in difficult cases.

Rare presentation of gastric outlet obstruction with jejunal impaction of gall stones-the Bouveret’s syndrome

Gall stones related complications are very common in the world, Bouveret’s syndrome is one of the rare complications (1-3%). Bouveret’s syndrome presents a diagnostic and therapeutic challenge. We present a rare case of an 80-year-old lady diagnosed with gastric outlet obstruction with jejunal impaction of gallstones, because of a gallstone impacted in the jejunum 50 cm from duodenojejunal flexure. The patient was operated on with enterotomy and retrieval of gall stones impacted in the jejunum, with roux en y gastrojejunostomy drainage procedure, the gastro-duodenal fistula was left in situ, because of high risk and unstable general condition of our patient intra-operatively. The patient had multiple pre-existing pre and peri-operative comorbidities, fortunately, our patient recovered and our patient was discharged on 21st postoperative days. Identifying Rigler’s triad symptoms is synonymous with diagnosing Bouveret’s syndrome. However, classical Rigler’s triad is present in only 40% of cases, hence alertness and a high degree of suspicion are required to differentiate Bouveret’s syndrome from other mechanical causes of gastric outlet obstruction. The atypical cases of Bouveret’s syndrome present a challenge to the surgeon for early diagnosis and therapeutic surgical management.

A255 CHOLECYSTO-COLONIC FISTULA AND GASTRIC OUTLET OBSTRUCTION DUE TO EXTRINSIC COMPRESSION: A RARE BOUVERET-LIKE SYNDROME

Abstract Background Bouveret syndrome is a rare form of gastric outlet obstruction due to gallstone ileus. It is caused by passage of a large stone from the gallbladder into the duodenum via a bilio-duodenal fistula causing gastric outlet obstruction. It was first described by Leon Bouveret in 1896 and occurs most commonly in elderly patients with a higher incidence in women. In classic Bouveret syndrome, the stone itself becomes impacted in the intestinal lumen. A case series of 128 cases found only 2 cases where the endoscopic finding was of extrinsic compression. Purpose To present a rare case of Cholecysto-colonic fistula and gastric outlet obstruction due to extrinsic compression as a rare Bouveret-like syndrome. Method Chart review was conducted including clinical notes, laboratory, radiographic, and endoscopy reports. A relevant literature review was conducted. Result(s) A 76-year-old female with recent hospitalization for weight loss, anemia and cognitive decline presented to hospital with sudden onset vomiting without abdominal pain. She was admitted to general surgery. CT scan of the abdomen and pelvis were done and described a subhepatic inflammatory mass with inflammation of the proximal duodenum causing a partial gastric outlet obstruction as well as a fistula between with hepatobiliary system and a loop of ascending colon with associated pneumobilia. The etiology of the fistula was unclear but thought to be due to infection vs malignancy vs stone disease and the patient was put on antibiotic therapy. Due to inability to tolerate oral intake, she was put on parenteral nutrition. The Gastroenterology (GI) service was then consulted for consideration of gastroscopy and possible stent placement for obstruction. The GI service requested an MRI for further characterization. This revealed a 20mm impacted gallstone in the fistula tract with 3 other similarly sized stones passed into the colon, as well as evidence of a partial outlet obstruction due to the inflammatory mass in the porta hepatis. Gastroscopy was pursued to identify any intraluminal compression, which revealed duodenal edema in the first segment of the duodenum without any intraluminal pathology. Given that the compression was not intraluminal, a stent was not offered. Surgical options would be extensive surgery including cholecystectomy, duodenal wedge resection and partial colonic resection. Given her comorbidities, plan was made for conservative management instead. After 2 weeks of admission and conservative management, her outlet obstruction resolved and she was able to tolerate oral intake again. Image Conclusion(s) Impacted gallstones causing chronic cholecystitis can result in fistula formation with the colon and due to the size of the stones in the tract and resultant inflammation, extrinsic compression of the duodenum may occur presenting as clinical gastric outlet obstruction. In this event, conservative management can be an effective strategy of management as a safe alternative to extensive surgical resection and bypass. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared

Clinics in diagnostic imaging (216).

Clinics in diagnostic imaging (216).

Impacted gallstone within a cholecystoduodenal fistula: endoscopic laser lithotripsy to the rescue

Video 1A large, impacted gallstone is treated unsuccessfully with electrohydraulic lithotripsy; however, fragmentation and removal is accomplished using endoscopic laser lithotripsy.

OGBN P09 Sharing the experience of the use of Spyglass DS - guided electrohydraulic lithotripsy (SG-EHL) in the treatment of large gallstone causing Bouveret syndrome

Abstract Background Less than 1% of intestinal obstruction is accounted for by gallstone ileus. Gallstone ileus is a mechanical intestinal obstruction resulting from gallstone impaction within the gastrointestinal tract. Under 3% of gallstone ileus are caused by gallstone impaction in the duodenum or pylorus, which can give rise to a gastric outlet obstruction, described by Bouveret in 1896. Surgical intervention involves the removal of the stone by either a gastrotomy or duodenotomy, which is associated with significant morbidity. Advancement in endoscopic techniques, allows for more complex procedures, therefore, reducing the need for a surgical intervention and its accompanying morbidity. This abstract presents a rare case of a large gallstone (22mm×34mm) partially impacted in the duodenum of a 92-year-old female, which was treated with the Spyglass DS-guided electrohydraulic lithotripsy (DS-EHL). Methods A 92-year-old female with a previous history of gallstone ileus was treated by surgical intervention. The patient continued to complain of abdominal discomfort and occasional vomiting. A CT scan revealed a fistulous communication to the duodenal bulb, containing a large gall stone (22mm x34 mm). After consultation with the patient, an initial assessment with the use of standard endoscopy under general anaesthesia confirmed the visualisation of a portion of the gallstone in the duodenum, hanging through a well-established cholecysto-dudenal fistula. SPyglass DS - guided lithotripsy (SG-EHL) was used in the treatment of the large gallstone. Results Electrohydraulic lithotripsy (EHL) was attempted through the standard gastroscope, but we were unable to secure a safe position to target the stone. Therefore, a side view duodenoscope was used along with the SpyGlass DS to obtain good visualisation and stable access to target the stone with the EHL. The Spyglass guided electrohydraulic lithotripsy (SG-EHL) was used to fragment the stone. Despite consuming four EHL wires and using higher settings, we only managed to break the shell of the stone, reducing its size by approximately 3mm all around. The laser was not available at the time; therefore, the procedure was concluded. The patient had an uneventful recovery and was discharged home. No further symptoms were recorded by patient on follow up 5 months later. Conclusions Endoscopic management of an impacted gallstone causing gastric outlet obstruction is found to be safe and carries less morbidity than the traditional surgical approach. Therefore, it should be considered for being the procedure of choice to treat patients with Bouveret syndrome. Laser lithotripsy should be available on standby for cases that involve stones that are harder to break.