University of Alabama at Birmingham Birmingham, AL, United States
Michael Mullarkey, MD1, Page Axley, MD1, Ramzi Mulki, MD1, Kondal Baig, MD1, Shajan Peter, MD2 1University of Alabama at Birmingham, Birmingham, AL; 2University of Alabama at Birmingham School of Medicine, Birmingham, AL
Introduction: Bouveret syndrome is a rare cause of gastric outlet obstruction due to passage of a gallstone into the proximal duodenum via a bilioenteric fistula. Historically, these patients have required invasive surgical management, including enterolithotomy, cholecystectomy and even partial enterectomy in cases of severe bowel ischemia. We present a case of Bouveret syndrome successfully treated endoscopically with laser lithotripsy and stone removal via Roth net.
Case Description/Methods: A 56-year-old woman presented with nausea, postprandial emesis, abdominal pain, and decreased oral intake for three days. Aside from mild epigastric tenderness and a mildly elevated total bilirubin of 1.9, her exam and labs were normal. CT abdomen revealed a cholecystoenteric fistula with 3 cm gallstone at the junction of the first and second portion of the duodenum with associated pneumobilia and locules of gas in the gallbladder, suggestive of Bouveret syndrome. Prior to any surgical intervention, the decision was made to attempt endoscopic stone removal. An upper endoscopy was performed, which confirmed a large stone in the duodenal bulb. Removal with a Roth net was initially attempted, though only small fragments were able to be freed. Laser lithotripsy was then performed (Holmium laser lithotripter; 1.2/14; 14.4 watts). Several larger stone fragments were dislodged, though the main stone was still too large to be extracted through the pylorus. The patient was discharged home on a clear liquid diet with plan for follow-up endoscopy. On repeat EGD, laser lithotripsy treatment was performed, which enabled the stone to fit into a Roth net retriever and be extracted through the pylorus into the stomach. At this point, the stone remained too large to pass through the esophagus, so lithotripsy was again performed until the stone broke into two pieces. Each piece was successfully extracted via Roth net retriever and the patient was discharged home without complication.
Discussion: Bouveret syndrome is a rare form of proximal duodenal ileus and gastric outlet obstruction that has historically required surgical management. These patients are often elderly with significant comorbidities putting them at higher risk for operation. In this case, two sessions of endoscopic lithotripsy were performed to remove a 3 cm gallstone from the proximal duodenum without the need for surgical intervention.
Disclosures: Michael Mullarkey indicated no relevant financial relationships. Page Axley indicated no relevant financial relationships. Ramzi Mulki indicated no relevant financial relationships. Kondal Baig indicated no relevant financial relationships. Shajan Peter indicated no relevant financial relationships.
Michael Mullarkey, MD1, Page Axley, MD1, Ramzi Mulki, MD1, Kondal Baig, MD1, Shajan Peter, MD2. P1763 - Endoscopic Management of Bouveret Syndrome With Lithotripsy and Roth Net Removal, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.