S3241 A Rock in a Hard Place: Endoscopic and Surgical Management of Bouveret Syndrome

Introduction: Bouveret syndrome is a rare complication of cholelithiasis that occurs when a large gallstone migrates through a bilioenteric fistula, most commonly cholecystoduodenal, and becomes lodged in the duodenum, leading to gastric outlet obstruction. Case Description/Methods: We present the case of an 87-year-old woman with a history of diabetes and prior hysterectomy who presented with epigastric pain and bilious emesis after a fatty meal. Imaging revealed pneumobilia, gastric outlet obstruction, and a 31 mm obstructing gallstone in the duodenum (Rigler’s triad). Upper endoscopy confirmed a large stone in the duodenal bulb and a visible cholecystoduodenal fistula. Despite the gamut of attempts at endoscopic retrieval including a Roth net, a large snare, rat tooth forceps, suction, and electrohydraulic lithotripsy (EHL), endoscopic retrieval was not successful. The patient subsequently underwent a laparoscopic enterotomy with successful stone extraction via jejunostomy. Cholecystectomy and fistula repair were deferred to minimize operative risk given the patient’s age. She recovered uneventfully and was discharged on postoperative day 5. Discussion: This case highlights several key aspects of Bouveret syndrome that would be valuable to clinicians: characteristic signs and symptoms of the syndrome, imaging features, and a description of endoscopic as well as surgical approaches. Endoscopic management is often preferred in elderly or high-risk patients, surgical intervention remains the most definitive treatment following failed endoscopy.