P4959 - Stuck Between a Rock and a Hard Place: When Endoscopic Therapy Fails for the Management of Bouveret Syndrome

Manu Dwivedi, MD¹, Sohil Khurana, DO², Pratik Patel, MD², Mohamad Abouzeid, MD², Robert Baranowski, MD^2
1Mather Hospital, Northwell Health, Chatsworth, CA; ²Mather Hospital, Northwell Health, Port Jefferson, NY

Introduction: Bouveret Syndrome (BS) is a rare form of gastric outlet obstruction secondary to a gallstone entering the small bowel, commonly through a bilioenteric fistula. It affects < 0.5% of patients with gallstones.

Case Description/Methods: A 92-year-old woman with history of hypertension, untreated renal cell carcinoma, diverting loop colostomy, and saddle pulmonary embolism treated with rivaroxaban presented to the emergency department with acute onset of nausea, emesis, decreased ostomy output, and progressive weakness for three days. She was tachycardic with right upper quadrant tenderness to palpation on physical exam. Laboratory evaluation revealed a significant leukocytosis (19.13 K/uL), anemia (10.6 g/dL), elevated alkaline phosphatase (149 u/L), lipase (488 u/L), and lactate (2.6 mmol/L). CT of the abdomen and pelvis demonstrated a large cholecystoduodenal fistula and luminal obstruction of the duodenum.
A double channel therapeutic upper endoscope revealed evidence of the fistula at the duodenal sweep and a gallstone completely obstructing the third portion of the duodenum. After attempts to remove the impacted stone with a guidewire and biliary balloon, a cholangiscope was inserted to perform electrohydraulic lithotripsy (EHL). Despite use of 6 EHL probes, only approximately 15% of the stone fragmented. The procedure was aborted. She later underwent laparoscopy converted to open duodenotomy with ileocecectomy. Intraoperative findings revealed a friable 4cm gallstone in the third portion of the duodenum.

Discussion: BS is a rare diagnosis with high morbidity and mortality. Stones often obstruct the distal stomach or proximal duodenum. Luminal obstruction in the third portion of the duodenum, as presented, is atypical. Risk factors for BS include calculi > 2.5cm, female sex, and age > 70 years. Symptoms are nonspecific (e.g., abdominal pain, nausea/vomiting, and dyspepsia). Imaging may reveal Rigler’s Triad (ectopic gallstone, pneumobilia, and small bowel obstruction). Current management of BS includes endoscopy, laparoscopy, and open surgical options. EHL is a potential option for patients who fail endoscopic removal. It is important to note that endoscopic management requires a high degree of expertise. Approximately two-thirds of stones can be visualized with endoscopy, and even fewer are successfully removed.
While there are currently no formal treatment guidelines for BS, this case highlights the importance of recognizing when to pursue surgical intervention after endoscopic therapy fails.



Disclosures:


Manu Dwivedi, MD¹, Sohil Khurana, DO², Pratik Patel, MD², Mohamad Abouzeid, MD², Robert Baranowski, MD². P4959 - Stuck Between a Rock and a Hard Place: When Endoscopic Therapy Fails for the Management of Bouveret Syndrome, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.