Large Gallstone Research Articles

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.

Rare finding of a porcelain gallbladder in an early 20th‐century asylum cemetery: Radiologic, clinical, and bioarchaeological perspectives

AbstractPorcelain, or calcified, gallbladder is a finding rarely identified in archaeologically excavated remains. This study reports on an ovoid calcification found in the torso of adult skeleton from an early 20th‐century mental asylum cemetery in Mississippi. The calcified object was imaged using conventional x‐ray and computerized tomographic (CT) scanning (standard and micro), which produced images consistent with those of a clinically diagnosed porcelain gallbladder containing a single large gallstone. The aim of this paper is to raise awareness of this medical condition, which may not be familiar to most anthropologists, and of the efficacy of CT scanning for the identification of calcified gallbladders, which may increase the number of cases reported in archaeological literature and provide more information about the prevalence of this condition, and gallbladder disease in general, in past populations.

New trends in diagnosis and management of gallbladder carcinoma.

Gallbladder (GB) carcinoma, although relatively rare, is the most common biliary tree cholangiocarcinoma with aggressiveness and poor prognosis. It is closely associated with cholelithiasis and long-standing large (> 3 cm) gallstones in up to 90% of cases. The other main predisposing factors for GB carcinoma include molecular factors such as mutated genes, GB wall calcification (porcelain) or mainly mucosal microcalcifications, and GB polyps ≥ 1 cm in size. Diagnosis is made by ultrasound, computed tomography (CT), and, more precisely, magnetic resonance imaging (MRI). Preoperative staging is of great importance in decision-making regarding therapeutic management. Preoperative staging is based on MRI findings, the leading technique for liver metastasis imaging, enhanced three-phase CT angiography, or magnetic resonance angiography for major vessel assessment. It is also necessary to use positron emission tomography (PET)-CT or 18F-FDG PET-MRI to more accurately detect metastases and any other occult deposits with active metabolic uptake. Staging laparoscopy may detect dissemination not otherwise found in 20%-28.6% of cases. Multimodality treatment is needed, including surgical resection, targeted therapy by biological agents according to molecular testing gene mapping, chemotherapy, radiation therapy, and immunotherapy. It is of great importance to understand the updated guidelines and current treatment options. The extent of surgical intervention depends on the disease stage, ranging from simple cholecystectomy (T1a) to extended resections and including extended cholecystectomy (T1b), with wide lymph node resection in every case or IV-V segmentectomy (T2), hepatic trisegmentectomy or major hepatectomy accompanied by hepaticojejunostomy Roux-Y, and adjacent organ resection if necessary (T3). Laparoscopic or robotic surgery shows fewer postoperative complications and equivalent oncological outcomes when compared to open surgery, but much attention must be paid to avoiding injuries. In addition to surgery, novel targeted treatment along with immunotherapy and recent improvements in radiotherapy and chemotherapy (neoadjuvant-adjuvant capecitabine, cisplatin, gemcitabine) have yielded promising results even in inoperable cases calling for palliation (T4). Thus, individualized treatment must be applied.

Bouveret’s syndrome from 2 large gallstones — a rare complication of gallstones

Bouveret’s syndrome from 2 large gallstones — a rare complication of gallstones

Contemporary diagnosis and management of gallbladder polyps

Gallbladder (GB) polyps are present in 5%–10% of the general population and consist of true neoplastic polyps (adenomas) and pseudopolyps (predominantly cholesterol, inflammatory, hyperplastic, focal adenomyomatosis). True polyps, although relatively rare neoplastic lesions (0.5%) are considered an important factor in malignant transformation and cancer development (5%) when their size is ≥ 1 cm. Given that it is essential to diagnose GB adenocarcinoma at an early stage to optimize therapeutic management, controversy exists about whether cholecystectomy is always necessary. Their imaging characteristics, size ≥ 1 cm, age > 50 years and genetic predisposition determine the indications for immediate cholecystectomy. In younger patients with polyps < 1 cm in size and without a familial history of GB carcinoma, imaging follow-up by ultrasound (US) seems to be a reasonable recommended policy. A scoring system by multivariate analysis (cross-sectional area > 123 mm2, positive blood flow signal, age > 55.5 years, alanine aminotransferase (ALT) levels > 50 U/L and an ALT/AST (aspartate aminotransferase) ratio > 0.77) can accurately predict true polyps. The widely accepted size threshold for US follow-up is 7 mm, and for intervention, it is 10 mm. Computed tomography or better magnetic resonance imaging can overcome any misdiagnosis of conventional US incidental findings alone that may lead to potentially unnecessary operations. In challenging cases, high-resolution US, novel three-dimensional US, endoscopic US or contrast-enhanced endoscopic US could be helpful. Novel microflow imaging can safely predict polyps. Risk factors for malignancy include age > 60 years, large gallstones, primary sclerosing cholangitis, Asian ethnicity and sessile polyps accompanied by focal gallbladder wall thickening > 4 mm. For polyps sized 6–9 mm, the absence of growth at recommended follow-up (6 months, one year, and two years) indicates treatment discontinuation; however, it is not required for size < 5 mm without risk factors. In addition to laparoscopic cholecystectomy, the standard management, novel interventional modalities preserving the GB in selected cases include per-oral transmural endoscopic resection of GB polyps after a bridge of endoscopic US-guided cholecystostomy or laparoscopic gallbladder-preserving polypectomy. Generally, there are still no precise and strong evidence-based guidelines; thus, the management policy of GB polyps should be individualized in ambiguous cases.

Delayed presentation of gallstone ileus due to spilled gallstones: A case report

Introduction: Gallstone ileus is a rare cause of intestinal obstruction and very few cases have been reported of spilled gallstones during a cholecystectomy resulting in a delayed presentation of gallstone ileus. Although complications from unretrieved gallstones are rare, there is a variety of post-operative complications described in the literature. Most complications occur within the first few months but can occur up to 10 years after the procedure. If complications arise, they may lead to significant morbidity and management may result in an invasive intervention, including a laparotomy. Case Report: An 83-year-old female underwent laparoscopic cholecystectomy for acute cholecystitis, during which several large gallstones spilled and an attempt at retrieval was made. Six years later, she presented to the emergency department with a small bowel obstruction due to gallstone ileus caused by an unretrieved spilled gallstone. She underwent laparotomy, and the gallstone was retrieved from the terminal ileum. Conclusion: Gallstone ileus can occur because of unretrieved spilled gallstones from a cholecystectomy. Although complications from unretrieved gallstones are rare, this case report highlights the importance of considering this as a differential diagnosis when patients present with symptoms consistent with intestinal obstruction after a cholecystectomy. It is important to attempt to retrieve spilled gallstones during cholecystectomy, but if this is not feasible, this should be documented, and patients should be informed of the potential risks of unretrieved stones although rare.

To compare the efficiencies of shock waves extracorporeal lithotripsies (ESWL) versus ureterorenoscopy (URS) to remove proximate ureteric stones

Introduction: - Urolithiasis is a widespread health problem. The objective of this research was to contrast the use of shock waves extracorporeals lithotripsies’ (ESWL) versus ureterorenoscopy (URS) for the proximal ureteric stones treatment. Ureteric stone is a common disease of urinary system in Pakistan. Despite ongoing success in endourological stone treatment, question about optimal management of proximal ureteric stone still remains debatable amongst urologist; therefore this study is being performed to find an appropriate and effective tool to treat ureteric stones.
 Objective: - For patients with large proximal ureteric gallstones, our goal was to compare the advantages of ureterorenoscopy with shock wave extracorporeal lithotripsy (ESWL) (10–15 mm).
 Settings: The Karachi-based Sindh Hospital of Urology & Transplantation's Urology Department.
 Duration: 6 months from 28-01-2022 to 28-07-2022
 Design: Randomized control trial
 Subject and Methods: Sixty people were enrolled in the trial, all of whom had a single, radio-opaque stone in the proximal ureter detected by IVU. Thirty patients received ESWL and thirty received URS, both at random. After 3 weeks, x-ray KUB was used to monitor patients in both groups. A computerized pre-structured proforma was used for all data collection.
 Result: - The victims were 27.58 6.20 years old on aggregate.There were 38(63.3%) male and 22(36.7%) female. Efficacy of URS treatment was significantly high as compare to ESWL [93.33% vs. 60%; p 0.002]. 
 Conclusion: - This research shows that the results support the hypothesis that URS is more effective for proximal ureteric stone clearance than ESWL.

Treatment of Bouveret syndrome with stone fragmentation using an endoscopic submucosal dissection knife

Video 1Treatment of Bouveret syndrome with stone fragmentation using an endoscopic submucosal dissection knife. A 61-year-old man with a 3-decade history of recurrent cholecystitis presented to the community emergency department with severe right upper quadrant pain. A CT scan was performed and revealed gangrenous cholecystitis with likely cholecystoduodenal fistulous communication.After discussion with the patient and the HPB team, the plan was made to attempt endoscopic extraction of the obstructing stone. This would be performed in the operating room, such that if endoscopic extraction was not possible, surgical management would proceed.During the endoscopy, 1 L of liquid material was suctioned and the retained solids were cleared as best as possible. The large obstructing stone was then seen in the duodenal cap. In the cap, we could appreciate the obstructing stone and the fistulous tract.We then passed a guidewire distal to the stone and advanced a 15- to 20-mm extraction balloon over the guidewire. The balloon was passed distal to the stone and inflated to 20mm. We then applied firm, steady traction in an attempt to extract the stone.With the double-channel gastroscope, we passed a second wire and extraction balloon distal to the stone to increase the amount of traction that could be applied. Both balloons were inflated distal to the stone, and steady, firm traction was again applied. Unfortunately, this was not successful either.We then decided to use a regular ERCP needle knife to incise the stone. Because the knife was delicate, it was easily deformable, so we decided to switch to a triangle-tip knife.Using the "PreciseSECT" mode on the electrosurgical unit, the stone was repeatedly incised. Particular care was taken to avoid flinging the knife and damaging the duodenal wall.Saline was used as the irrigation solution to ensure electrosurgical conductivity when the current was applied.At this point, we could appreciate fragmentation of the stones after repeated incision.After about 3 hours of stone incision and fragmentation, the guidewire was passed beyond the stone; the extraction balloon was advanced over the wire; and the balloon was again inflated with steady traction applied. This time, the stone was successfully extracted from the stomach.The duodenum was then examined. There were no remaining large pieces of stone or any significant mucosal damage or perforation.Using a mechanical lithotripter, the remaining larger fragments of stone were fragmented and extracted. However, because the stone had a large diameter, lithotripsy at the center was not initially possible, and the smaller lateral aspects had to be performed until the stone was completely fragmented.This case demonstrates the incision and fragmentation of a massive gallstone with the use of an endoscopic submucosal dissection knife and electrosurgical unit.With cautious application of this technique, successful endoscopic management of a large gallstone causing Bouveret syndrome was achieved. This technique avoided open surgical management and allowed for elective cholecystectomy at a later date with less morbidity.

539 Antegrade Manipulation and Retrieval per Rectum: A Novel Management Approach for Gallstone Coleus

Abstract Gallstone ileus is a rare complication of gallstone disease, while gallstone coleus is rarer still. Like gallstone ileus, it affects mainly elderly female patients. It is associated with high mortality and morbidity, as frailty is a significant issue in the patient demographic. In this case report, we discuss a 94-year-old, who presented with large bowel obstruction secondary to a large gallstone in the mid-sigmoid colon. Neither conservative management nor retrieval via flexible sigmoidoscopy were successful. Due to worsening bowel obstruction, the decision to operate was made. Due to frailty, a pre-operative decision was made that she would not be for bowel resection or enterotomy. A hybrid flexible sigmoidoscopic/ laparotomy assisted removal was successful: a Pfannenstiel incision was made, the stone was milked distally, and eventually retrieved with flexible sigmoidoscopy via the anus. We propose that in frail patients, a combined approach using laparotomy and flexible sigmoidoscopy may be considered as a method of gallstone removal. This avoids the significant risks associated with enterotomy or bowel resection.

118 Bouveret Syndrome: A Rare Case of a Huge Gallstone causing Gastric Outlet Obstruction

Abstract Introduction Bouveret syndrome is a rare case of gallstone ileus resulting from an acquired fistula connecting the gallbladder and either the stomach or duodenum and cause intestinal obstruction. Case Summary A 85-year-old female presented with epigastric pain non-bilious vomiting and absolute constipation for five days. She patient was tachycardiac and was dehydrated. Abdomen was distended. Bowel sounds were absent. Digital rectal examination was unremarkable. Abdominal radiography did not demonstrate pathological air-fluid levels, rather revealed a dilated gastric shadow, suggestive of gastric outlet obstruction. The patient was immediately managed with nasogastric intubation and intravenous hydration. Subsequent esophagogastroduodenoscopy (EGD) was planned to rule out carcinoma owing to the age of the patient. EGD revealed a dilated stomach and a hard, golf-ball-sized gallstone in the third part of the duodenum. The scope could not be passed beyond the impacted stone, nor could it be extracted endoscopically. CT tomography revealed a distended stomach with a large gallstone obstructing duodenum and pneumobilia . One-stage surgical procedure was planned. Intraoperative findings included a thick-walled gallbladder with surrounding inflammation and a fistulous tract connecting the gallbladder with the duodenum. A gallstone measuring 3.7cm in diameter was retrieved from the third part of duodenum via enterotomy. The fistulous tract was closed, and cholecystectomy was performed and drain was placed. Patient was discharged on 4th postop day. Conclusion Bouveret syndrome is an infrequent presentation causing gastric outlet obstruction and is often overlooked owing to its rarity. High index of suspicion is necessary when patients present with bowel obstruction and a history of gallstones to prevent morbidity and mortality from Bouveret syndrome.

The Rigler’s triad: a case of gallstone ileus

Rigler’s triad is an extremely rare syndrome that accounts for 4% of all cases of small intestinal obstruction (SBO). This illness is distinguished by three clinical and radiological features: pneumobilia, a severe intestinal blockage, and an abnormally placed gallstone in the gallbladder. An 84-year-old woman arrives at the Emergency Department with symptoms of SBO. The CT scan is essential for detecting the trio. An emergency laparoscopy with an enterotomy and gallstone extraction was conducted successfully. The Rigler’s triad should be suspected in elderly individuals with a history of gallstones in the gallbladder, especially in the emergency scenario. Large and solitary gallstones in the gallbladder that are asymptomatic should be candidates for cholecystectomy. In conclusion, this case is a very didactic instance, particularly because of the crisp CT images that can assist surgeons in identifying gallstone ileus and the mini-invasive method that can also benefit in an emergency context.

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.
 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.

Gallstone Ileus, A Rare Yet Deadly Cause of Small Bowel Obstruction

Introduction:Gallstone ileus is a rare cause of intestinal obstruction. It commonly affects older patients with significant medical conditions. This disease has a high mortality rate (12-17%), hence should be an important diagnosis to consider, especially as the geriatric population grows worldwide.Method: Case Report:84-year old gentleman, with diabetes and ischemic heart disease, presented with diarrhea, vomiting and fever for one day. He was febrile, tachycardic and hypotensive. There was lower abdominal tenderness with guarding. Labs done revealed metabolic acidosis with a raised lactate along with raised inflammatory markers. Impression was intra-abdominal sepsis, with a need to rule out mesenteric ischemia. He underwent CTAP which revealed gallstone ileus. The gallbladder was collapsed and pneumobilia was present in keeping with fistulation. Dilated small bowel loops were present with a transition point at the distal jejunum or proximal ileum, where there are two gallstones. Patient underwent exploratory laparotomy. There was an obstructing large gallstone 100cm from the DJ flexure. After removal of gallstone and decompression, the bowel was pink with areas of bruising. Patient was hypotensive intra-operatively likely contributed by septic shower, requiring dual vasopressors. He was transferred to the ICU post-operatively and developed cardiogenic shock with type 2 respiratory failure precipitated by sepsis. He demised on Day 2 post-operatively.Results:Gallstone ileus is caused by intestinal impaction of a gallstone that has migrated through a cholecystoenteric fistula. The classic radiologic sign of gallstone ileus is Rigler's triad. This is only picked up 15% of the time on plain abdominal x-rays. Early CT scans can reveal Rigler triad up to 80% of the time. Surgical management remains the cornerstone of treatment.Conclusion:Gallstone ileus remains a diagnostic challenge as patients present with non-specific signs and symptoms. It is prudent for emergency physicians to consider this disease in elderly patients who present with small bowel obstruction.

Transjejunal ERCP, EUS-guided gallbladder drainage, and cholecystoscopy with direct electrohydraulic lithotripsy with large gallstone removal in Roux-en-Y anatomy.

Video 1Transjejunal ERCP, EUS-guided gallbladder drainage, and cholecystoscopy with direct electrohydraulic lithotripsy with large gallstone removal in Roux-en-Y anatomy.

Gallstone Ileus with A Typical Clinical Presentation: A Case Repor

Introduction: Gallstone ileus is a rare complication of cholelithiasis, described as a mechanical intestinal obstruction due to the impaction of one or more large gallstones within the gastrointestinal tract. It is caused by the passage of a gallstone from the bile ducts into the intestinal lumen through a fistula. The most frequent type of fistula is located between the gallbladder and the duodenum. Clinical Case: A 60-year-old male was admitted with a diagnosis of DM 2 / hypovolemic shock / upper gastrointestinal bleeding. Began 24 h before admission, presented asthenia, adynamia, hyporexia, tolerating only a liquid diet, 3 vomits of gastric contents and one melenic evacuation. level of care for surveillance and diagnostic protocol, upon admission to this hospital he presented vomiting in coffee grounds and hypotension that responded to intravenous fluids. An exploratory laparotomy was performed, finding: obstruction of the small intestine by a gallstone of approximately 7 cm in diameter at 170 cm from the angle of Treitz, reactive appendicitis, and abundant inflammatory reaction fluid; Enterolithotomy + primary closure was performed with the Heineke-Mikulikcz technique and a Penrose drain was placed into the pelvic cavity. Discussion: Intestinal obstruction caused by gallstones is rare, this event occurs more frequently in the elderly. The clinical picture is often diffuse and requires a high index of suspicion. Conventional radiography can be of great help for its diagnosis, but also Abdominal Ultrasound and Computerized Axial Tomography. Surgical treatment can range from enterotomy and lithotomy, which is the simplest, to enterotomy with lithotomy plus cholecystectomy, and fistula treatment, which is a complex procedure.

Clinics in diagnostic imaging (216).

Clinics in diagnostic imaging (216).

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.

OGBN P13 Management of Bouveret Syndrome: an endoscopic approach

Abstract Background Bouveret syndrome is rare complication of gallstones with 600 reported cases since 1950. The syndrome occurs when adhesions develop between the gallbladder to surrounding hollow viscera leading to fistula formation. Large gallstones migrate into the enteric system and become impacted in the stomach or duodenum causing gastric outflow obstruction. Bouveret syndrome accounts for 1–4% of gallstone ileus cases. It is more common in co-morbid women in their 7th and 8th decades. Most common symptoms are vomiting and abdominal pain. Upper gastrointestinal bleeding is reported in 15% of cases. CT scan has the highest sensitivity at 79–93% to make the diagnosis. Of note 15–25% of gallstones are isoattenuating. Riglers triad is a diagnostic marker and consists of aerobilia, a gastric outflow obstruction or dilated bowel and the presence of a calculus outside of the biliary tree. The diagnosis was associated with mortality rates as high as 30% but with modern advances mortality has decreased to approximately 12%. Treatment options are surgical or endoscopic retrieval. Endoscopic management carries less risk especially in the frail elderly patient. This approach has low success rates. We present a case of successful endoscopic management of Bouveret syndrome and discuss surgical and endoscopic management strategies. Methods A frail 83 year old female attended ED with epigastric pain, vomiting and signs of sepsis. She had a recent diagnosis of severe cholecystitis that was managed conservatively. On examination she had tenderness in the right upper quadrant. Bloods revealed an AKI, a CRP 189 and normal liver function tests. Axial imaging showed aerobilia with a CBD dilated at 14mm and there was a 3.5cm calculus impacted in the duodenum with a cholecysto-duodenal fistula. Her medical history included diabetes mellitus, atrial fibrillation, hypertension, primary hyperparathyroidism, reflux and cauda equina (operated). On OGD there was a large stone which had eroded into the first part of the duodenum. A combination of mechanical lithotripsy and the Kudo snare were used to fragment the stone. 2 large fragments were retrieved using a bag to avoid gallstone ileus. Results The patient had an uneventful but slow recovery. She re-established oral intake on the second post-operative day. She was discharged 2 weeks later without complication. Conclusions The success of endoscopic management is reported as low as 10%. Endoscopic intervention is attempted in 61% of cases. Success is more likely with stones <4cm and if the site of impaction is the stomach or D1/D2. Surgical management is associated with a morbidity rate of 26% but was successful in 78%. Laparoscopic surgery is possible but less successful in stones >5cm. Endoscopic techniques have evolved and should be considered for extraction of stones in the first instance. If not feasible surgery can be considered. The literature shows that success is more likely when various endoscopic techniques are utilized including mechanical lithotripsy, nets and baskets, extracorporeal shock wave lithotripsy, electrohydraulic lithotripsy, laser lithotripsy and duodenal stenting. There is a risk of distal migration of stone fragments causing gallstone ileus in the more distal small bowel. Bouveret syndrome can be resolved with endoscopy in expert hands.

S348 Creating Your Own Paths: EUS-Guided Transjejunal Gallbladder Drainage and ERCP, Cholecystoscopy, and Electrohydraulic Lithotripsy for Choledocholithiasis and Cholelithiasis in a Patient With Roux-en-Y Gastric Bypass

Introduction: Treating choledocholithiasis and cholelithiasis in patients with altered gastrointestinal anatomy is a challenge given the difficulty in accessing the biliary tract using conventional endoscopic techniques. Endoscopic ultrasound (EUS) directed transgastric ERCP (EDGE) represents a novel solution to this challenge. It allows access to the excluded stomach allowing safe performance of ERCP and interventional EUS procedures including gallbladder drainage. Case Description/Methods: A 61-year-old man with a history of morbid obesity, Roux-en-Y gastric bypass, and bowel perforation complicated by extensive resection and short gut syndrome, as well as rheumatoid arthritis and chronic kidney disease, presented to clinic for intermittent right upper quadrant pain, nausea, and vomiting. Imaging revealed large cholelithiasis, choledocholithiasis, and biliary dilatation with gallbladder distention. Given his high surgical risk and symptomatic biliary disease, EDGE and EUS-guided management of the large gallstone was planned. The first step was to create a jejunogastrostomy (JG) which was performed using EUS-guided 15mmx10mm lumen-apposing metal stent (LAMS) deployment through the Roux limb into the excluded stomach. ERCP was performed 4 weeks later finding choledocholithiasis, and complete removal of two stones was accomplished. This was followed by EUS-guided gallbladder drainage via JG and successful creation of a cholecystoduodenostomy (CDS) using the 15mmx10mm AXIOS stent system. Direct cholecystoscopy, electrohydraulic lithotripsy and removal of a large gallstone were then performed. Both LAMS from JG and CDS were removed at the end of the procedure. Follow-up upper GI series at 6 weeks showed complete closure of the jejunogastrostomy fistula. Discussion: The EDGE approach provides access to the excluded remnant stomach enabling ERCP and interventional EUS procedures such as gall bladder drainage. In this case, we demonstrate the utility of this procedure in enabling access to the gallbladder and permitting direct cholecystoscopy, electrohydraulic lithotripsy, and removal of a large symptomatic gallstone, thus avoiding long-term percutaneous drains and recurrent symptoms, in addition to the risk of cholecystitis or Mirizzi syndrome from a large gallstone. Watch the video at https://tinyurl.com/ACGAbstractS348