Bouveret syndrome masquerading as a gastric mass-unmasked with endoscopic luminal laser lithotripsy:A case report

BACKGROUND 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.CASE SUMMARY 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.CONCLUSION 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.

Gastric Outlet Obstruction by a Hydrocholecyst. A Very Rare Variant of Bouveret Syndrome: A Case Report

It is estimated that between 0.3% - 0.5% of patients with cholelithiasis have biliary ileus, of this small proportion, only between 1% - 3% is complicated by the syndrome described in 1896 by Leon Bouveret. Bouveret syndrome refers to the obstruction of the gastric outlet tract secondary to the passage and impactation of a gallstone in the duodenum, through a cholecystoduodenal fistula. It is most common in women, between the ages of 74 - 77 and is clinically characterized by pain, bloating, incoercible vomiting and anorexia.

Post hoc validation of a tool that accurately predicts the outcome of endoscopic therapy in Bouveret syndrome

Background Bouveret syndrome is characterized by gallstone impaction in the upper gastrointestinal tract causing gastric outlet obstruction.In Bouveret syndrome,endoscopic gallstone removal can avert the need for surgery.However,in cases in which endoscopic therapy is unlikely to succeed,endoscopic attempts delay definitive treatment and compound patient risks.We previously developed a model that predicts endoscopic outcomes from data derived through a systematic review.This tool uses gallstone length,site of impaction,and the number of planned methods of lithotripsy to predict the likelihood of endoscopic success with an accuracy of 81.0%.This study aimed to evaluate our tool performance in an independent,non-training data set and assess endoscopic and surgical outcomes.Methods Systematic searches of the PubMed,Scopus,and Cochrane databases were performed for articles published between 16 April 2018 and 1 June 2021.The data reported after our previous study were harvested and inputted into the tool to evaluate their ability to accurately predict outcomes when compared with actual outcomes.Results Newly collated data in fields of interest showed no significant statistical differences compared with previous training data sets.Endoscopic therapy was successful in 41.9%of cases.Gallstones of ≤4 cm had a higher chance of successful endoscopic intervention(odds ratio 6.7,95%confidence interval 1.7–25.8,P<0.01).Complications of surgery were reported in 29.5%;there was one fatality reported.Post hoc evaluation of our predictive tool demonstrated an AUROC score of 0.80.Conclusions We have demonstrated in an independent data set that the tool can be used to accurately predict outcomes of endoscopic therapy.Patients in whom endoscopic therapy is most likely to fail should be offered an early surgical opinion.

Successful endoscopic treatment of a large impacted gallstone in the duodenum using laser lithotripsy,Bouveret’s syndrome:A case report

BACKGROUND Bouveret´s syndrome is defined as a gastric outlet obstruction after passage of a gallstone through a fistula into the duodenum.Due to its rarity,the diagnosis of Bouveret’s syndrome is often delayed and causes a high morbidity and mortality rate.CASE SUMMARY A 93-year-old female presented with worsening pain in the right upper abdomen and vomiting.A gastroscopy revealed fluid retention caused by a massive obstructive stone in the bulbus.Endoscopic laser lithotripsy of the impacted stone was planned after multidisciplinary consultation.A Dornier Medilas H Solvo lithotripsy 350μm laser fiber(10 Hz,2 Joules)was used to disintegrate the stone into smaller pieces.The patient recovered completely.CONCLUSION A mechanical obstruction due to a gallstone that has entered the gastrointestinal tract is a complication that appears in 0.3%-0.5%of patients who have cholelithiasis.Stones larger than 2 cm can become impacted in the digestive tract,which occurs mostly in the terminal ileum.In approximately 1%-3%of cases,the stones cause obstruction in the duodenum.This phenomenon is called Bouveret’s syndrome.As this condition is mostly observed in elderly individuals with multiple comorbidities,treatment by an open surgical approach is unsuitable.Endoscopic removal is the preferred technique.The benefit of using laser lithotripsy is the precise targeting of energy onto the stone with minimal tissue injury.Endoscopic laser lithotripsy is a safe and feasible treatment option for Bouveret’s syndrome.