A 77–year–old Caucasian female with a history of morbid obesity, breast cancer status post bilateral mastectomy with reconstruction, deep venous thrombosis, and hypertension presented with a 5–day history of abdominal pain, nausea and bilious emesis with decreased oral intake. She was still having multiple small bowel movements at the time of admission. She admitted to a history of right upper quadrant pain that was would come and go over the past several years. Physical examination revealed mild tenderness to palpation in the mid–epigastric and right upper quadrant. A CT scan of her abdomen showed a suspected biliary–enteric fistula with a large gallstone in the third portion of the duodenum. Because of her comorbidities, she was determined not to be an operative candidate and a gastroenterology consult was obtained for potential endoscopic intervention. Initial endoscopic evaluation revealed a 5 cm gallstone impacted in the second section of the duodenum as well as a biliary–enteric fistula. At that time, the patient underwent a total of three sessions of endoscopic laser lithotripsy and stone removal with subsequent resolution of the obstruction.
Gallstone disease is a common gastrointestinal cause of abdominal pain with a prevalence of up to 10% in the United States and Western Europe. Complications of gallstone disease include acute cholecystitis, ascending cholangitis, and acute pancreatitis. A more rare complication of gallbladder disease is gallstone ileus, which compromises 1–4% of cases of intestinal obstruction usually at the level of the terminal ileum. Bouveret’s Syndrome represents an uncommon cause of gallstone ileus with an estimated incidence of 1–3% of the total number of cases. Smaller gallstones can pass through the cystic duct and common bile duct to the small intestine. Larger gallstones such as those seen in Bouveret’s Syndrome cannot pass through the normal ductal system and instead erode through the gallbladder wall into the lumen of the duodenum. This process is questionably accelerated by inflammation caused by chronic cholecystitis. Clinical symptoms typically are similar to cholecystitis. Diagnosis is typically made based on the presence of pneumobilia, demonstration of duodenal obstruction and visualization of lithiasis by radiography or ultrasonography. Treatment is typically surgical with enterolithotomy with or without cholecystectomy and fistula repair. Fistula repair is considered unnecessary as it may spontaneously close, especially if there are no residual gallstones and the cystic duct remains patent. Nine percent of patients are successfully managed non–surgically including endoscopic laser or mechanical lithotripsy with stone removal. Only 5% of patients respond to extracorporeal shock–wave lithotripsy.
This presentation highlights the role of specialized endoscopic therapy in the management of complicated gallstone disease.