2170 Endoscopic Management of Gastric Outlet Obstruction Due to a Large Gallstone ("Bouveret's Syndrome")

INTRODUCTION: Bouveret's syndrome is referred to a gastric outlet obstruction due to an impacted gallstone in the duodenum following cholecystoduodenal fistula. Surgery is required in certain cases, but the mortality rate is up to 30 %. Endoscopic management has been reported with a low success rate. We demonstrate a successful endoscopic mechanical and electrohydraulic lithotripsy of a large gallstone causing gastric outlet obstruction. CASE DESCRIPTION/METHODS: A 88 years old female presented with a three-day history of right upper quadrant abdominal pain (RUQ), nausea, and non-bilious vomiting. Past medical history is significant for hypertension, coronary artery disease, and type 2 diabetes. Vital signs were normal. Pertinent findings included tenderness to palpation in the epigastric and RUQ regions, normal bowel sounds, and a loud succession splash. Labs revealed Hgb 10.2 g/dl, WBC 7k/mm3, platelets 289k/mm3, BUN 13 mg/dl, creatinine 0.6 mg/dl. Plain abdominal X-ray showed round calcified structure in the right mid abdomen (Figure 1). CT scan of the abdomen showed 4 cm × 3.5 cm gallstone causing complete obstruction of the duodenum, cholecystoduodenal fistula, pneumoperitoneum, and distended stomach (Figure 2). Upper endoscopy revealed a large gallstone impacted in the first part of the duodenum, extensive ulceration of the duodenal wall with a small perforation at the site of stone impaction (Figure 3). Mechanical and electrohydraulic lithotripsy was performed, and the stone was fragmented into small pieces in the duodenum. There was spontaneously sealed duodenal perforation with fat and omental plug. The endoscopic lithotripsy was performed without difficulty. The patient was improved, tolerated an oral diet, and discharged home in a stable condition. DISCUSSION: Bouveret’s syndrome is a rare cause of gastric outlet obstruction and characterized by impaction of a gallstone within the pylorus or duodenum. It occurs mostly in elderly, female patients with an average age of 70 years. Given that most patients are elderly with multiple comorbidities, they are poor surgical candidates. The endoscopic approach is considering to be a good alternative. As we demonstrated in our case, these patients can be successfully managed endoscopically with lithotripsy despite the low success rate that was reported in the literature. Endoscopic treatment is effective and safer and should be considered as a first line option.