2 Gastroenterology Research and Practice kV Figure 2: Endoscopic image showing the gallstone causing obstruc- tion.Figure 1: A gallstone in the duodenum and a distended stomachwas seen on CT scan.stomach and a 3.3 cm hypodense oval object in the secondportion of the duodenum suggestive of Bouveret’s Syndrome(Figure 1).2.3. Management. Initial esophagogastroduodenoscopy(EGD) revealed large amounts of ﬂuid and food contentin the stomach with poor visualization of the duodenumdue to retained food and a large stone in the secondpart of duodenum causing complete obstruction of itslumen (Figure 2). Extensive ulceration of the duodenalwall at the point where the stone was impacted was alsoseen. The patient was brought back the following day forattempted stone extraction, at which time the stone wassuccessfully removed from the duodenum and transferredto the stomach using various devices including a retrievalnet, snare, stone extracting basket, and lithotripsy basket. Figure 3: Fistula and surrounding ulceration of the duodenum onA cholecystoduodenal ﬁstula was visualized beneath the endoscopy.level of the stone on subsequent endoscopy (Figure 3). Thestone was then successfully crushed into smaller fragmentsusing a mechanical lithotripter. After successful endoscopic and subsequent passage of gallstones via the ﬁstula can thentreatment, the patient’s symptoms resolved and he was result in gallstone ileus .discharged home with close follow-up as an outpatient. The most common location where a gallstone gets “stuck” is in the ileum (84%), usually in the terminal portion. In 1–3% of cases, however, the gallstone gets lodged in3. Discussion the duodenum and causes symptoms consistent with gastricCholelithiasis is a relatively common health problem; by age outlet obstruction; it is this rare condition that is known as75, about 35% of women and 20% of men have developed Bouveret’s Syndrome . The syndrome was ﬁrst describedgallstones . While the majority of patients with gallstones by Beaussier in 1770 and was subsequently named after thedo well, a small percentage of patients (approximately 6%) French physician Leon Bouveret after he published two casedevelop complications including such rare complications as reports in Revue de Medecin in 1896 .cholecystoduodenal ﬁstulas . Fistula formation is thoughtto occur as a result of adhesions between the gallbladder 3.1. Diagnosis. In most cases, the presenting signs andand the bowel wall from chronic inﬂammation, impaired symptoms of Bouveret’s syndrome are nonspeciﬁc. In aarterial blood supply and decreased venous drainage . recent systematic review, Cappell and Davis described theEnsuing ﬁstula formation can occur from pressure necrosis most common symptoms of patients with Bouveret’s syn-and compression of a gallstone against the gallbladder wall, drome as nausea and vomiting (86%), and abdominal pain
Gastroenterology Research and Practice 3(71%); less commonly, patients present with hematemesis, Dumonceau et al. reported a case of successful treatmentweight loss, and anorexia . On physical exam, patients with IEHL after failure of ESWL . Two additional casesoften have abdominal tenderness, abdominal distention, and described by Huebner et al., in 2007 saw the incorporationdehydration. of IEHL as the sole modality with successful stone extraction The diagnosis of Bouveret’s syndrome is usually made . The risk involved with this method is that inadvertentvia endoscopy. Grove, in 1976, was the ﬁrst to describe a focusing of the shockwaves onto the intestine wall may causecase of pyloric obstruction due to a gallstone as diagnosed bleeding and perforation.by gastroscopy . On endoscopy, visualization of a stone Extracorporeal shockwave lithotripsy (ESWL) has alsocausing obstruction is seen in about 69% of patients and been used with success in treating patients with Bouveret’sobstruction in the absence of a visualized stone or ﬁstula is syndrome [15, 19–21]. Limitations of using ESWL includeseen in 31% of cases . In the remaining cases, the stone the need for several return sessions, in addition to eventualmay not actually be visualized because it is compressing the endoscopy. Also, ESWL may be diﬃcult to perform in obeselumen and only partially visualized through the duodenal patients or if there are gas-containing bowel loops interposedwall. Other ﬁndings described include excessive retained between the gallstone and the abdominal wall [15, 19–21].food or ﬂuid in the stomach and inﬂammation, edema, or In general, the success rate of endoscopic extractionulcer at the impacted site . is dependent on stone size. Stones, that are larger than Radiologic imaging tests can often conﬁrm the diagnosis 2.5 cm are more diﬃcult to extract endoscopically, althoughof Bouveret’s syndrome. CT is diagnostic in about 60% extractions of stones up to 3 cm, have been reported .of cases and is helpful in demonstrating the exact level of Larger stones can cause ischemic ulceration of the adjacentobstruction, the biliary site of the duodenal ﬁstula, and the duodenal wall. Moreover, these stones tend to have a hardstatus of the gallbladder [10, 11]. Approximately 15–25% outer shell and soft inner core making mechanical frag-of gallstones are isoattenuating and not well visualized on mentation with endoscopic forceps or laser more diﬃcult.CT. In such cases, magnetic resonance cholangiopancreatog- While the majority of patients tolerate attempted endoscopicraphy (MRCP) may be useful, because it may more clearly treatment, there has been a case report of pulseless electricaldelineate ﬂuid from calculi. activity (PEA) during mechanical retrieval due to the gallstone getting lodged in the esophagus; the PEA abruptly3.2. Treatment. Endoscopic extraction, endoscopic laser resolved when the stone was pushed back into the stomach.lithotripsy (ILL), extracorporeal shockwave lithotripsy In a handful of cases, surgery was needed subsequent to(ESWL), and intracorporeal electrohydraulic lithotripsy upper endoscopy due to stricture, sepsis, and a second stone(IEHL) have all been reported as alternatives to surgery in the duodenum .for more proximal gallstone obstruction whereas surgery is If endoscopic treatment fails, the patient will requireroutinely recommended for individuals with impaction of surgical management. Forty-two percent of surgical patientsthe gallstone more distally (gallstone ileus). have previously undergone a failed endoscopic treatment. Endoscopic treatment of Bouveret’s syndrome should Surgical options include a combination of enterolithotomybe considered a ﬁrst-line option despite the low success (removal of the stone) plus cholecystectomy and ﬁstularate reported in the literature. The ﬁrst successful endo- repair, but surgery is associated with signiﬁcant morbid-scopic extraction was described in 1985 by Bedogni et al. ity and mortality [22–26]. Combined treatment has been. Subsequently, a number of case reports have been associated with a higher mortality of 20–30%, compared topublished describing successful endoscopic management of just 12% in cases of simple duodenotomy. Laparoscopy isBouveret’s syndrome [3, 6–14]. Endoscopic management also an additional option for surgical treatment; Sica et al.often necessitates the use of diﬀerent sized and shaped snares, reported, in 2005, the ﬁrst case of uneventful stone removalgrasping forceps, retrieval baskets and nets, biliary balloons, and cholecystectomy by laparoscopy .and sometimes even a side-viewing endoscope; it can be Although debatable, ﬁstula repair in patients treatedtechnically challenging, time-consuming, and success rates with endoscopic methods or simple enterolithotomy isin case series have been previously reportedly to be less than often considered unnecessary due to spontaneous closure,10% . especially when the cystic duct is patent and no residual Endoscopic treatment, accompanied by lithotripsy using stones are present. On the other hand, the persistence ofa variety of diﬀerent modalities, has been well described. symptoms, the possibility for recurrence, and the risk forThere are several reports of intracorporeal laser lithotripsy gallbladder cancer lend support to ﬁstula repair.(ILL) alone, and in combination with, ESWL [6, 14–16]. Theﬁrst reported successful use of ILL was in 1999 by Maiss et 4. Conclusionsal. requiring a total of nine sessions . The drawbacksof this particular procedure are the need for prolonged and Prior case series have reported low success rates with endo-multiple sessions, and the risk of converting a proximal scopic treatment (9%) however it is likely that endoscopicgallstone ileus into a distal gallstone ileus (as a result of success rates are much higher now, as more innovativepartial fragmentation of the stone). endoscopic techniques are used to treat these patients. The IEHL can be used alone or in combination with other use of mechanical and intracorporeal lithitripsy allows largermethods. Moriai et al. used IEHL with mechanical lithotripsy stones to be managed, and should be considered the ﬁrst-linefor removal of two 3 cm stones in 1991 . In 1997 of therapy for this rare condition.
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