Background:

Bouveret syndrome is a rare manifestation of gallstone ileus, accounting for less than 3% of cases, and arises from the impaction of a gallstone in the pylorus or duodenum via a bilioenteric fistula (1,2). It predominantly affects elderly patients with long-standing cholelithiasis and is associated with delayed diagnosis, significant morbidity, and high mortality (1,3). The optimal management approach remains debated, particularly in frail patients (4,5). We report a case of Bouveret syndrome in a 92-year-old female successfully treated using combined endoscopic lithotripsy techniques, demonstrating the viability of minimally invasive management in high-risk individuals.

Case Description:

A 92-year-old female with advanced frailty and multiple comorbidities presented with right upper quadrant pain, nausea, and vomiting. Computed tomography revealed pneumobilia, a cholecystoduodenal fistula, and a large duodenal gallstone causing gastric outlet obstruction. Endoscopic evaluation confirmed an 8 cm impacted gallstone in the duodenal bulb. Electrohydraulic and mechanical lithotripsy were used to fragment and mobilise the stone into the stomach, achieving complete clearance in a three-hours endoscopic procedure, done under general anaesthesia.

Outcome:

The patient’s symptoms and liver function tests normalised post-procedure. Subsequently, she developed a distal gallstone ileus due to migration of a fragment. Given a predicted high perioperative mortality, conservative management was chosen. Spontaneous passage of the stone ensued, with full radiological and clinical resolution, and the patient was discharged in good condition.

Conclusion:

Endoscopic lithotripsy represents a safe and effective alternative to surgery for Bouveret syndrome in frail, elderly patients (4,5). Early CT or MRCP imaging is key to diagnosis (3), while multidisciplinary, patient-centred management optimises outcomes in this rare but serious complication of gallstone disease (4,5).

Keywords:

Bouveret syndrome; Endoscopic lithotripsy; Gastric outlet obstruction; Cholecystoduodenal fistula; Gallstone ileus