S5289 Bouveret Syndrome in a Patient With Gastric Bypass Status Post EDGE/EHL for Treatment

Introduction: Bouveret syndrome is an uncommon type of gallstone ileus characterized by gastric outlet obstruction from a gallstone that has migrated through a cholecystoenteric fistula into the stomach or duodenum. Bouveret syndrome represents a small amount of gallstone ileus cases and presents with symptoms such as nausea, vomiting, abdominal pain, and weight loss. Bouveret syndrome has a high mortality rate, especially if there is a delay in diagnosis, with a substantial risk of serious complications and death. We report the case of a 67-year-old man with a history of Roux-en-Y gastric bypass who presented with Bouveret syndrome. This case shows the value of advanced endoscopic approaches, such as Endoscopic ultrasound-directed transgastric ERCP (EDGE) and electrohydraulic lithotripsy (EHL), in treating complex patients with Bouveret syndrome. Case Description: Sixty-seven-year-old man with past medical history of Roux-en-Y gastric bypass presented with acute onset abdominal pain for 2 days. The patient underwent computed tomography of the abdomen and pelvis showed a 3.7 cm rounded lesion in the proximal duodenum along with free air in the gallbladder fossa and peritoneum. Despite resuscitation, the patient remained hemodynamically unstable, and the patient was deemed not an optimal surgical candidate. MRCP revealed a cholecystoduodenal fistula and gallstone. The excluded stomach was accessed with a lumen apposing stent, and EHL of the obstructive stone in the duodenum was performed. Due to the prolonged duration of procedure, the stone fragments were not retrieved. A repeat endoscopy was performed several weeks later to confirm clearance of the stone. The cholecysto-duodenal fistula was visualized and appeared patent, and a repeat endoscopy removed the lumen apposing stent. Discussion: Bouveret syndrome remains a challenging diagnosis as it relies on high clinical suspicion and imaging modalities. Endoscopy is both diagnostic and therapeutic, but technically challenging and many patients ultimately require surgical interventions. EDGE creates a gastrogastric fistula to access the excluded stomach, and is considered a first line approach especially in elderly patients with comorbidities. The successful dilation of the fistula and stone fragmentation via electrohydraulic lithotripsy supports EDGE as a viable, less invasive alternative to surgery in complex cases of Bouveret syndrome.