Published online Nov 26, 2020. doi: 10.12998/wjcc.v8.i22.5701
Peer-review started: August 2, 2020
First decision: September 24, 2020
Revised: October 8, 2020
Accepted: October 26, 2020
Article in press: October 26, 2020
Published online: November 26, 2020
Processing time: 114 Days and 19.9 Hours
Bouveret syndrome, also known as gallstone ileus, is a rare form of gastric outlet obstruction accounting for 1%-3% of cases. This condition is most often reported in females. The diagnosis can be challenging and is often missed due to atypical presentations, which occasionally mimic gastric outlet obstruction symptoms such as nausea, vomiting, loss of appetite and hematemesis. The symptoms vary with stone size. Larger stones are managed with a surgical approach, but this carries increased morbidity and mortality. Over the past decade, the endoscopic approach has emerged as an alternative mode of treatment, but it is generally unsuccessful in the management of larger-sized stones. A literature review revealed cases of successful endoscopic treatment requiring multiple sessions for stone sizes measuring up to about 4.5 cm. Here we present a unique case of an elderly patient with Bouveret syndrome with a 5 cm stone mimicking a gastric mass and causing gastric outlet obstruction, who was successfully managed in a single session using a complete endoscopic approach with laser lithotripsy.
An 85-year-old female patient presented with 1-month history of intermittent abdominal pain, vomiting, decreased appetite and weight loss. An abdominal computed tomography showed a 4.5 cm × 4.7 cm partially calcified mass at the gastric pylorus causing gastric outlet obstruction. Endoscopy showed an ulcerated fistulous opening and a large 5 cm impacted gallstone in the duodenal bulb. Endoscopic nets and baskets were used in an attempt to remove the stone, but this approach was unsuccessful. Given her advanced age, poor physical condition and underlying comorbidities, she was deemed to be high-risk for surgery. Thus, a minimally invasive approach using endoscopic laser lithotripsy was attempted and successfully treated the stone. Post-procedure, the patient experienced complete resolution of her symptoms with no complications and was able to tolerate her diet. She was subsequently discharged home at 48 h, with an uneventful recovery.
In our paper we describe Bouveret syndrome and highlight its management with a novel endoscopic approach of laser lithotripsy in addition to various other endoscopic approaches available to date and its success rates.
Core Tip: An elderly female presented with features of gastric outlet obstruction found to have a large gall stone of 5 cm on endoscopy, successfully treated with complete endoscopic approach with laser lithotripsy.