Bouveret’s syndrome (BS) is a rare form of gallstone ileus that can result in benign gastric outlet obstruction (GOO). It occurs when a gallstone migrates through the cystic wall, forming a cholecystoenteric fistula with subsequent impaction of the calculous material in the duodenal lumen. (1) (2) (3)

We report the case of an 80-year-old woman presenting with chronic abdominal pain, weight loss, and sudden-onset vomiting. Initial evaluation was challenging due to cognitive impairment and early dementia. However, blood tests and computed tomography (CT) imaging revealed a 50 mm gallstone impacted in the duodenal bulb, associated with acute cholecystitis. CT additionally showed gastric dilation secondary to duodenal obstruction. Although BS has traditionally been managed surgically, often requiring laparotomy and limited small-bowel resection, the patient’s frailty prompted a multidisciplinary decision to pursue a less invasive endoscopic approach. (4)

Initial management included nasogastric decompression and intravenous proton-pump inhibitor therapy. Subsequent upper gastrointestinal endoscopy confirmed the presence of food debris in the stomach and a 50 mm impacted gallstone obstructing the pyloric outlet. Electrohydraulic lithotripsy (EHL) was performed under direct endoscopic visualization using a high-power setting (pulse level 15) to facilitate fragmentation.

Given the substantial size and calcified consistency of the stone, all eight EHL probes available in our center were used during the first session, achieving partial fragmentation and permitting advancement of the endoscope into the second portion of the duodenum. A second procedure was performed 48 hours later, resulting in complete fragmentation. Stone debris and fragments were extracted using a polyp retrieval net and standard polypectomy snare. The cumulative procedure time was approximately three hours, requiring a total of 12 probes. After stone extraction, two large, round Forrest III ulcers were identified on the lateral wall of the duodenal bulb, while the opening of the cystic duct with adjacent cholecystic mucosa was visualized on the medial wall. Clinical and endoscopic follow-up at ten days confirmed complete symptom resolution, successful clearance of all stone material, and healing of the duodenal ulcers. This case demonstrates successful endoscopic management of duodenal Bouveret’s syndrome in a frail, surgically ineligible geriatric patient.