East Tennessee State University Fort Worth, TX, United States
Award: Presidential Poster Award
Syed Madeeha Sadiq, DO1, Hoylan Fernandez, MD2, Jacque Rampy, MD2, Kumar Gutta, MD2, Arthi Kumaravel, MD2 1East Tennessee State University, Fort Worth, TX; 2Baylor All Saints Medical Center, Fort Worth, TX
Introduction: Cholelithiasis can present with complications such as cholecystitis, choledocholithiasis, or cholangitis. Bouveret Syndrome is a rare condition in which the inflamed gallbladder creates a fistula into the duodenum or stomach and passes a stone large enough to cause an obstruction. There are no standardized treatments for this type of gallstone ileus, but three common approaches include endoscopy, laparoscopy, and open surgery.
Case Description/Methods: A 74 year old female presented to the hospital from an outside facility due to small bowel obstruction. She initially presented with a two day history of intractable vomiting. She underwent CT, which showed gastric outlet obstruction from a presumed 4 cm fungating mass in her duodenum. Her EGD showed an ulcerated mass completely obstructing the lumen of the second portion of the duodenum so she was transferred for further management. Her WBC count was 15.1K/uL and lipase was 1,323IU/L, but other labs were unremarkable. At our facility, an MRI (Figures 1A and 1B) showed a choledochal fistula and a 5 cm stone rather than a mass. After consultation by hepatobiliary surgery, it was elected to pursue an endoscopic approach due to the difficult retroperitoneal location of the stone in the second portion of the duodenum. EUS confirmed that the obstruction was from a stone with no tumor seen. With an endoscopic approach, Electrohydraulic Lithotripsy (EHL) was used to fragment the stone and retrieve them via Roth net (Figures 1C, 1D and 1E). The stone was not able to be completely fragmented due to its size and density. A repeat EGD with EHL or laser was planned for the following day. The patient developed recurrent abdominal pain the next day, and a repeat CT showed the stone had migrated into the proximal jejunum. It was now more surgically accessible and was removed with an enterotomy and primary closure (Figure 1F).
Discussion: Bouveret syndrome is a rare condition causing non-malignant intestinal obstruction. There are newer minimally invasive techniques that we can attempt, avoiding open abdominal surgery. EHL uses shock waves generated via an electric high voltage spark and efficiently fragments stones. It is typically used now for large common bile duct stones, but we used it in the duodenum. Although in this case surgery was unavoidable due to migration of the stone, an initial endoscopic approach may often be curative with the advent of newer modalities such as laser lithotripsy and EHL.
Figure: Figure 1A: MRI of obstructive stone. Figure 1B: MRI showing fistula between gallbladder and duodenum. Figure 1C: Endoscopic image of obstructive stone in the second portion of the duodenum. Figure 1D: EHL of stone. Figure 1E: Net retrieving stone. Figure 1F: Stone within jejunum.
Disclosures: Syed Madeeha Sadiq indicated no relevant financial relationships. Hoylan Fernandez indicated no relevant financial relationships. Jacque Rampy indicated no relevant financial relationships. Kumar Gutta indicated no relevant financial relationships. Arthi Kumaravel indicated no relevant financial relationships.
Syed Madeeha Sadiq, DO1, Hoylan Fernandez, MD2, Jacque Rampy, MD2, Kumar Gutta, MD2, Arthi Kumaravel, MD2. P0097 - An Unusual Case of Gastric Outlet Obstruction: Bouveret Syndrome, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.