Novel endoscopic approach for Bouveret syndrome: a case report on successful lithotripsy with laser for giant duodenal gallstone removal

Abstract

Bouveret syndrome is a rare form of gastric outlet obstruction resulting from gallstone migration through a bilioenteric fistula. Fewer than 300 cases have been reported in the literature, to our knowledge. We present the case of a 68-year-old man with severe postprandial pain, recurrent vomiting, and significant weight loss. Laboratory tests revealed severe anemia, metabolic acidosis, and acute kidney injury. Imaging and upper endoscopy identified a large duodenal gallstone associated with a cholecystoduodenal fistula and ischemic gastric ulcers. The patient underwent endoscopic management with laser lithotripsy and fragment extraction, achieving complete resolution of the obstruction. This case highlights the feasibility and effectiveness of endoscopic therapy, particularly laser lithotripsy, as a minimally invasive alternative to surgery in patients with Bouveret syndrome who present with high surgical risk.

Introduction

Bouveret syndrome (BS) is a rare form of gastric outlet obstruction (GOO) secondary to a gallstone due to a bilioduodenal fistula.¹ Chronic cholelithiasis can lead to increased luminal pressure, compromising blood flow to the intestinal wall, leading to ischemia, perforation, and subsequent gallstone passage into the bowel.² This rare condition accounts for approximately 1% to 3% of all cases of gallstone ileus.³ Since 1770, several cases of duodenal obstruction due to gallstones have been reported. However, it was not until 1896 that BS was named in honor of the French physician Leon Bouveret, who published 2 case reports in the Revue Médicale.⁴ The disease predominantly affects elderly individuals and has a high morbidity and mortality rate of 60% and 30%, respectively,⁵ due to the difficulty in diagnosis and treatment. Since 2008, approximately 300 cases have been reported in the global medical literature,⁶ underscoring this condition's complexity and clinical challenges.

Case presentation

A 68-year-old man with a history of benign prostatic hyperplasia and otherwise no significant family or social history was admitted due to postprandial distress, abdominal pain, multiple episodes of vomiting, and significant weight loss (more than 10 kg in 1 year).

The physical examination showed a cachectic and pale patient with a distended bladder and abdominal pain without signs of peritoneal irritation. Laboratory tests revealed severe anemia, with a hemoglobin level of 7.6 g/dL (normal value [NV] >12 g/dL), hematocrit 24% (NV >36%), and arterial blood gases showing metabolic acidemia with acute kidney injury, with a creatinine level of 12.67 mg/dL (NV <1.2 mg/dL), a blood urea nitrogen level of 185 mg/dL (NV <20 mg/dL), and a glomerular filtration rate of 4 mL/min/1.73 m² (NV 90-120 mL/min/1.73 m²). He was admitted to the intensive care unit.

A point-of-care ultrasound revealed significant gastric distension with debris inside. Because a GOO was suspected, an upper endoscopy was performed.

Endoscopy was performed on the day of admission with the patient under general anesthesia using a Fujifilm ELUXEO 7000 system (Fujifilm Holdings, Tokyo, Japan). On entering the stomach, we aspirated most gastric contents, extracting 2000 mL of retained liquid. The presence of GOO was confirmed because of a giant duodenal stone (suggestive of a cholecystoduodenal fistula). Ischemic ulcers secondary to gastric overdistension and severe retention esophagitis were also visualized (Fig. 1). Initially, 3 attempts were made to extract the calculus using a 20- × 40-mm Dormia basket (Varfra S.A, Mexico City, Mexico), but all were unsuccessful. Subsequently, a holmium laser lithotripsy probe was introduced, applying 10 Hz and 1.5 J over the center of the calculus (Fig. 2A to D). This allowed an initial fragmentation of 30% of its size, achieving the disimpaction of the duodenal wall contralateral to the cystoduodenal fistula, which reduced the risk of ischemia in that area. After this, a noncontrast abdominal computed tomography scan (Fig. 3) was performed to assess the anatomy of the periduodenal region and to rule out a fistulized gallbladder neoplasm.

Figure 1.

Upper gastrointestinal endoscopy. A, Severe retention esophagitis with diffuse ulceration visualized. B, Signs of ischemia with ulcers (arrows) and distension in stomach. C and D, Overdistension and abundant gastric contents. E and F, A large gallstone (arrows) is visualized occupying the duodenal bulb and producing a gastric obstruction outlet.

Figure 2.

A, Lithotriptor console with settings used in the procedure (10 Hz and 1.5 J). B, Holmium laser lithotripsy probe (arrow). C, Initial fragmentation of the calculus (the arrow indicates the probe, and the asterisk highlights the gallstone impacted in the duodenal wall). D, Disimpaction of the gallstone from the duodenal wall was achieved (arrow). E, Large stone fragment in the stomach captured in a basket. F, Final endoscopic image showing resolution of duodenal obstruction, with the pylorus and clear duodenal bulb beyond visualized.

Figure 3.

Noncontrast abdominal computed tomography. The calculus (yellow arrow) in the duodenal lumen and the cholecystoduodenal fistula (red arrow) are evident in both images. A, Axial view. B, Coronal view.

In the second phase (the next day), stone fragmentation was completed using the same laser parameters, and complete lithotripsy of the giant duodenal stone was achieved (Fig. 2E and F). During the removal of 1 of the fragments, a deep mucosal tear with bleeding was found in the esophagogastric junction and in the last 2 cm of the distal esophagus. A fully covered self-expandable esophageal stent (8 cm × 24 mm) was placed and positioned adequately. This therapeutic choice was made considering the dual effect of the stent, providing both hemostasis and defect closure. A subsequent computed tomography scan confirmed correct positioning without evidence of perforation. A plan was made to remove the stent 3 days after insertion. In the postoperative period, the patient remained on parenteral nutrition for 5 days. Two days after the procedure, a liquid oral diet was reintroduced. No further adverse events occurred during hospitalization, and once his medical conditions stabilized, the patient was discharged after 12 days. The patient said he was very happy that the treatment was with a minimally invasive intervention. There is no report of the patient returning for follow-up after hospitalization.

Discussion

BS is characterized by a GOO caused by a gallstone that has migrated through a biliodigestive fistula, usually a cholecystoduodenal or choledochoduodenal fistula, and causes severe obstructive symptoms. Patients with BS typically present with nausea, persistent vomiting, abdominal pain, and anorexia.⁷ Sometimes, they may also present with Mallory-Weiss syndrome. Clinically, abdominal distension and dehydration can be detected.⁸

This case is noteworthy because of the presence of a huge stone and the use of a novel extraction technique in a condition where there is no consensus on optimal treatment, with no standardized treatment algorithm, highlighting the need for developing effective strategies in clinical practice.⁵ Mechanical lithotripsy and extracorporeal shock wave lithotripsy have been tried.⁶ The definitive management is usually surgical, because it allows stone removal plus treatment of the biliary-enteric fistula and the gallbladder. The classic option is enterolithotomy (via gastrotomy, pylorotomy, or enterotomy). In low-risk patients, a 1-stage approach (enterolithotomy + cholecystectomy + fistula closure) is preferred. In fragile or high-risk patients, a 2-stage approach is often chosen: first, enterolithotomy to relieve the obstruction, and later, cholecystectomy and fistula closure if symptoms or adverse events develop. Roux-en-Y duodenojejunostomy has been described as a way to manage large fistulas.³ Surgical adverse events include infection, persistent fistula, and duodenal stenosis, with high risk in multimorbid patients.

Endoscopic therapy, being minimally invasive, is preferred in high-risk surgical candidates. According to recent studies, outcomes depend largely on stone size, location, and available lithotripsy techniques. Stones <4 cm in diameter are significantly more likely to be successfully treated endoscopically (odds ratio: 6.7; 95% confidence interval: 1.7-25.8; P < .01),¹ with best outcomes in stones <2.5 cm.^2,9,10 Current strategies for the endoscopic treatment of BS include extraction with nets or baskets and various types of lithotripsy (mechanical, electrohydraulic, laser, and extracorporeal shock waves).^2,9,10 Lithotripsy, or fragmentation, will be necessary for the endoscopic removal of larger gallstones, and it must always be followed by the extraction of the different fragments to reduce the risk of distal ileus from the large stone fragments.

Electrohydraulic lithotripsy generates shock waves through a surrounding aqueous solution, fragmenting the stone. Although it carries a potential risk of bleeding and perforation, it is less expensive than laser lithotripsy, which offers greater precision and less tissue damage.

In the present case, given the patient's critical condition with acute renal failure, severe metabolic acidosis, and extreme gastric distension, an endoscopic strategy was chosen by a multidisciplinary team. This approach enabled successful fragmentation and removal of a giant duodenal stone arising from a cholecystoduodenal fistula, avoiding the higher morbidity associated with surgery.

The strength of this case illustrates the successful use of holmium laser lithotripsy for the treatment of a giant duodenal gallstone, a technique rarely reported in the literature, to our knowledge. It highlights the feasibility of endoscopic management as a minimally invasive alternative in a high-risk surgical patient with multiple comorbidities. The multidisciplinary approach ensured patient safety and optimized outcomes. The limitations include that this article describes a single case, which limits the generalizability of the findings. The procedure requires specialized equipment and expertise, which may not be available in all centers.

BS endoscopic therapy with laser lithotripsy may be a feasible, safe, and effective alternative to surgery in appropriately selected patients.

Patient consent

All participants in this study gave informed consent for treatment and open-access publication, which was obtained or waived. The Research and Research Ethics Committee issued approval 1115875. We hereby inform that on March 10, 2024, as recorded in minutes 19/2024, the Hospital's Research and Research Ethics Committee approved the review of the medical record in question to prepare a case report.

Disclosure

All authors disclosed no financial relationships.