Electrohydraulic lithotripsy and gallstone removal

Alireza Sedarat, MD, Division of Digestive Diseases, Department of Medicine, University of California Los Angeles, in Los Angeles, California, USA presents this VideoGIE case “Electrohydraulic lithotripsy and removal of a gallstone obstructing the duodenum: Bouveret syndrome.”

The case describes an elderly patient with advanced gallbladder cancer who presented with emesis and a presumptive diagnosis of malignant gastric outlet obstruction. During EGD intended for palliative enteral endoprosthesis placement, a large gallstone was found to be obstructing the duodenal lumen. This is consistent with Bouveret syndrome. The case highlights successful endoscopic treatment with destruction of the giant stones using electrohydraulic lithotripsy (EHL) and subsequent restoration of bowel continuity.

Figure 1. Endoscopic images showing stone impacted in the duodenum (A), lithotripsy being performed (B), fragmented stone being removed from the duodenum (C), and all stone fragments removed (D).

Bouveret syndrome is a rare but well recognized complication of gallstone disease that can  carry a high morbidity and mortality. These cases often occur in elderly patients with comorbidities that are otherwise poor operative candidates. The video demonstrates effective destruction of a giant intraluminal gallstone to effectively manage this patient endoscopically. It highlights the utility and efficacy of EHL for giant stones; these large stones are difficult to destroy, but ultimately will likely respond with patience and persistence.

Recognition of Bouveret’s syndrome, especially in a patient with malignancy, may be difficult as cross sectional imaging may not initially be diagnostic. The initial endoscopic evaluations of the proximal and second duodenum were unremarkable and it was only after deeper examination that the unexpected cause of the obstruction was recognized. Mechanical means to extract the stone failed, but EHL through a gastroscope was effective with persistence.

Find more VideoGIE cases online.

The information presented in Endoscopedia reflects the opinions of the authors and does not represent the position of the American Society for Gastrointestinal Endoscopy (ASGE). ASGE expressly disclaims any warranties or guarantees, expressed or implied, and is not liable for damages of any kind in connection with the material, information, or procedures set forth.

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