C0668 - Endoscopic Management of Bouveret‘s Syndrome in a Comorbid Patient

Sofi Damjanovska, MD¹, Elie S. Al Kazzi, MD², Sagarika Satyavada, MD², Brooke Glessing, MD³, Ashley Faulx, MD², Gerard Isenberg, MD^4
1Case Western Reserve University/University Hospitals Cleveland Medical Center, Cleveland, OH; ²Case Western University Hospitals/University Hospitals Cleveland Medical Center, Cleveland, OH; ³University Hospitals Cleveland Medical Center/ Case Western Reserve University, Cleveland, OH; ⁴University Hospitals Case Medical Center/ Case Western Reserve University, Cleveland, OH

Introduction: Bouveret’s syndrome is a gastric outlet obstruction (GOO) caused by an impacted gallstone in the duodenum or stomach via a bilioenteric fistula. The treatment is primarily surgical, but endoscopic therapy may be the only option for patients that are non-surgical candidates.

Case Description/Methods: A 78-year-old man presented with hematemesis and CT scan suggesting cholecystoenteric fistula leading to GOO. Due to multiple comorbidities, he was deemed a non-surgical candidate. Esophagogastroduodenoscopy (EGD) showed a large Forrest Class IIb ulcer in the duodenal bulb that was not amenable to endoscopic therapy. The patient then underwent endovascular embolization of the gastroduodenal and supraduodenal arteries. On day five, a second EGD showed a 3 cm gallstone impacted in the duodenal bulb. Under the gallstone was a partially obstructing Forrest Class IIc ulcer. Unsuccessful removal of the gallstone was attempted using a mechanical lithotripter basket and Roth net. On day ten, the gallstone was removed endoscopically using electrohydraulic lithotripsy (EHL) at a pulse rate of 10 and medium power setting. One stone fragment (~1 cm) remained, obscuring the lumen distal to the duodenal bulb. During the fourth EGD on day 14, the remaining gallstone was fragmented with rat-tooth forceps and lithotripsy basket. After balloon sweep of the presumed cholecystoduodenal fistula tract, contrast injected into the tract was seen draining into the duodenal bulb, precluding full fluoroscopic assessment of the fistula. The patient was discharged to a skilled nursing facility on day eighteen.

Discussion: Bouveret’s syndrome is a rare complication of cholelithiasis. Most common symptoms include epigastric pain, nausea, and vomiting. Patients can also present with non-specific signs, such as gastrointestinal bleeding, as did our patient. When surgical candidacy is limited by comorbid conditions, endoscopy is the preferred and possibly only therapeutic option. Gallstone removal may be done endoscopically, with mechanical, electrohydraulic, or laser lithotripsy. For impacted stones, mechanical fragmentation can be accomplished by using a basket, snare, forceps, mechanical lithotripsy, or EHL prior to extraction and removal. All stone fragments should be removed after mechanical fragmentation to avoid complications like gallstone ileus. In our case EHL was followed by mechanical fragmentation to accomplish complete fragmentation and removal.



Disclosures:


Sofi Damjanovska, MD¹, Elie S. Al Kazzi, MD², Sagarika Satyavada, MD², Brooke Glessing, MD³, Ashley Faulx, MD², Gerard Isenberg, MD⁴. C0668 - Endoscopic Management of Bouveret‘s Syndrome in a Comorbid Patient, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.