S5356 Cracking the Code: Successful Electrohydraulic Lithotripsy of Bouveret Syndrome

Introduction: Bouveret syndrome is a rare condition where a large gallstone passes through a bilioduodenal fistula, causing gastroduodenal obstruction. Current literature recommends endoscopic extraction and/or lithotripsy before surgery. However, successful endoscopic management diminishes as gallstones reach greater than 4 cm (9.8% vs 66.1%). We present a case where electrohydraulic lithotripsy (EHL) successfully resolves Bouveret syndrome caused by a large gallstone. Case Description: A 75-year-old man with history of hypertension and diabetes presented to an outside hospital (OSH) with coffee ground emesis for 1 day. Computed tomography (CT) of the abdomen and pelvis showed 4.5 cm lobulated mass eroding into the duodenum and thick-walled gallbladder with extraluminal gas. Initial esophagogastroduodenoscopy (EGD) at OSH found a Mallory-Weiss tear that was clipped and a cholecystoduodenal fistula with a large impacted stone in the proximal duodenum. Following initial stabilization, the patient was referred to our facility for further management. At our center, EGD confirmed the presence of the impacted gallstone. EHL was then performed to fragment the stone, followed by retrieval of fragments larger than 1 cm using lithotripsy baskets and retrieval net. The post-procedure course was uncomplicated, and the patient was subsequently referred to general surgery for an elective laparoscopic cholecystectomy. Discussion: Bouveret syndrome accounts for a small percentage of gallstone ileus cases and poses significant treatment challenges, especially when large gallstones are involved. Endoscopic approaches, while less invasive, have variable success rates, particularly with stones larger than 4 cm. Complications of endoscopic lithotripsy include distal small bowel obstruction due to fragment migration, duodenal perforation, and mucosal injury. However, careful fragmentation and retrieval of sizable stone pieces can mitigate these risks. Our case demonstrates that, with appropriate technique and equipment, endoscopic management can be a viable option even for large gallstones, mitigating the need for more invasive surgical interventions.