Post written by Ryan Law, DO, from the Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA.

We describe a case of an 80-year-old female who was referred for management of persistent choledocholithiasis. She had a past history of carcinoid. The patient presented with symptomatic choledocholithiasis 2 years prior and underwent ERCP with plastic biliary stent placement. The patient was lost to follow-up, returning 1 year later with biliary sepsis. Repeat ERCP was performed with stent removal, incomplete stone clearance, and suggestion of cholecystenteric fistula. The patient therefore underwent placement of a percutaneous transhepatic biliary drainage (PTBD). Following referral to our institution, PTBD was removed, and ERCP was performed for ductal clearance. No evidence of cholecystoenteric fistula was identified. Endoscopic examination revealed a subepithelial mass in the duodenal bulb, concerning for malignant carcinoid, but biopsies were non-diagnostic. The patient returned for an endoscopic ultrasound with fine needle aspiration (EUS-FNA) for further evaluation of the duodenal lesion. The duodenal mass appeared more ulcerated, allowing visualization of a suspected retained gallstone. The embedded gallstone was thought to be the result of fistula formation during a prior episode of cholangitis and presumed cholecystitis. The overlying mucosa was unroofed and extracted using a combination of a needle-knife papillotome and a ceramic tip electrosurgical knife.

We elected to remove the stone in this case. Stones >20 mm have been known to increase the risk of gallstone ileus or outlet obstruction, clinically known as Bouveret syndrome. Passage of large gallstones into the gastrointestinal lumen via cholecystoenteric fistula put patients at risk for gallstone ileus. Gallstones retained within the lumen wall should be unroofed and extracted endoscopically using a variety of endoscopic accessories.

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