Austin L. Chiang, MD, from Brigham and Women’s Hospital in Boston, Massachusetts, USA, presents this video case “Combined Mirizzi syndrome with Bouveret syndrome.”

An 87-year-old man initially presented with hematemesis and was found on CT scan to have a large gallstone in the duodenum with a possible cholecystoduodenal fistula, both of which were also noted on MRI/MRCP. Upper endoscopy revealed a 4cm round, pigmented gallstone in the duodenal bulb completely obstructing the lumen, consistent with Bouveret Syndrome. The large gallstone was ultimately fragmented and removed using electrohydraulic lithotripsy, wire basket, Roth net, and snare. Ulceration was noted in the duodenal bulb under which a fistulous opening was noted. Injection of contrast into this fistulous opening demonstrated filling of the gallbladder followed by immediate filling of the intrahepatic ducts, rather than sequential filling of the cystic duct and common bile duct. This therefore suggests a fistula between the gallbladder and the common hepatic duct, consistent with Mirizzi syndrome.

We feel that this video highlights not only a variety of endoscopic tools used in gallstone removal but also rare fistulous complications of gallstones. In our video, the choledochoduodenal fistula is consistent with a variant of Mirizzi syndrome, followed by erosion into the duodenum through a cholecystoduodenal fistula representing Bouveret syndrome.

Various tools can be employed to fragment large gallstones causing obstructive intestinal symptoms. Careful endoscopic examination for fistulous openings, followed by fluoroscopic evaluation may reveal rare pathophysiology.

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