P4547 - A Case of Bouveret Syndrome Treated With Electrohydraulic Lithotripsy in a Patient With Cirrhosis and Clostridioides difficile Infection

Fiorella A. Estrada, MD, Rami Abusaleh, MD, Ariana R. Tagliaferri, MD, Daniel Maas, MD, Savio Reddymasu, MBBS, FACG
Creighton University Medical Center, Phoenix, AZ

Introduction: Bouveret syndrome, a rare complication of cholelithiasis and chronic cholecystitis, involves gallstone migration through a bilioduodenal fistula, causing gastric outlet obstruction. Primarily affecting elderly women, it presents with nausea, vomiting, and epigastric pain. Timely recognition through patient history and imaging is crucial for prompt endoscopic or surgical treatment. This case of Bouveret syndrome alongside other gastrointestinal comorbidities, including cirrhosis with recent esophageal variceal bleeding and recurrent Clostridium difficile colitis, emphasizes the diagnostic process and therapeutic approaches.

Case Description/Methods: 65-year-old male patient with past medical history of NASH cirrhosis, esophageal varices, type II diabetes mellitus, stage 3 CKD, and hypertension presented with two days of nausea, vomiting, diffuse abdominal pain, and diarrhea. During a prior hospitalization he had esophageal variceal bleeding treated with variceal banding, Clostridium difficile colitis treated with oral vancomycin, and Candida glabrata fungemia treated with fluconazole. During this admission, CT abdomen pelvis revealed cholecystitis with a cholecystoduodenal fistula and a large gallstone causing gastric outlet obstruction. Treatment included ceftriaxone, metronidazole and gastric decompression. EGD with electrohydraulic lithotripsy was performed, in which the stone was pulverized and stone fragments were retrieved with a basket and Roth net, underscoring the efficacy of endoscopic management.

Discussion: Our case highlights Bouveret syndrome in a patient with a broad differential diagnosis given prior hospitalization of possible cholecystitis, portal vein thrombosis, esophageal variceal bleeding post-banding, and C. difficile colitis. While nausea and vomiting without hematemesis decreased suspicion of esophageal bleeding, complications from portal vein thrombosis or C. difficile colitis could explain symptoms. Imaging showed cholecystitis with a cholecystoduodenal fistula and gallstone causing gastric outlet obstruction, prompting consultations with gastroenterology for ERCP with lithotripsy and hepatobiliary surgery for potential surgical intervention. Successful lithotripsy avoided invasive treatments. This case emphasizes the overshadowing effect of comorbidities in elderly patients. Despite Bouveret syndrome's rarity, it is important to consider in patients with gastric outlet obstruction symptoms for timely intervention with ERCP and readiness for surgery if necessary.


Disclosures:


Fiorella A. Estrada, MD, Rami Abusaleh, MD, Ariana R. Tagliaferri, MD, Daniel Maas, MD, Savio Reddymasu, MBBS, FACG. P4547 - A Case of Bouveret Syndrome Treated With Electrohydraulic Lithotripsy in a Patient With Cirrhosis and <i>Clostridioides difficile</i> Infection, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.