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We read with interest the editor's quiz about Bouveret's syndrome by Yau et al (Gut 2006;55:373, 387). We noted the comments that these cases are usually dealt with surgically, and carry a high morbidity. Recently, we had a similar case, which was managed without surgical intervention using mechanical lithotripsy as normally used at endoscopic retrograde cholangiopancreatography, avoiding the need for laparoscopic surgery.
A 79‐year‐old woman was admitted with a 2‐month history of recurrent vomiting, abdominal pain and weight loss. A CT scan of the abdomen showed a grossly dilated stomach suggestive of gastric outlet obstruction due to stones in the second part of the duodenum (D2). A subsequent gastrografin follow through showed duodenal obstruction and a cholecystoduodenal fistula.
An oesophagogastroduodenoscopy showed an inflamed and narrowed pylorus with malignant‐looking ulcer and apparent gallstones in the D2. To relive the symptoms of obstruction, we wanted to remove the stones but the stones were too large to be moved in either antegrade or retrograde direction. Therefore, after dilating the pyloric stricture with a balloon, a mechanical lithotriptor was used to crush the stones, which were retrieved from the stomach with a Roth Net after being pulled back through the pyloric stricture.
The obstructive symptoms improved, but the biopsy specimens taken from the D2 confirmed the diagnosis of poorly differentiated adenocarcinoma of possible pancreatic origin and unfortunately she died 2 months after the admission.
Bouveret's syndrome was first described by Léon Bouveret in 1893 in Revue de médecine, where he reported two cases of this syndrome. It is a condition, that causes gastric outflow obstruction secondary to a gallstone impaction in the duodenum due to a cholecystodoudenal fistula. It is reportedly more common in women (65%). Typically, patients present with a few days' history of abdominal pain and vomiting but cases of haematemesis have been reported.1 The stones could be seen on plain abdominal film or a CT scan along with pneumobilia and gastric dilatation.
The main aim of managing Bouveret's syndrome is to relieve the obstruction by removing the stones, which can either be done surgically or endoscopically. Obviously, it is preferable to avoid a surgical approach if possible because of the associated morbidity and mortality, which is 15–18% according to one study.2 Therefore, endoscopic removal should be tried first before embarking on a surgical procedure. If the stones are large, as in our case, then laser3 or mechanical lithotripsy4 could be used to fragment the stones in the duodenum.
In the here‐reported case, the patient had underlying incurable malignancy and was not fit for surgery to relieve the symptoms of duodenal obstruction; therefore, we fragmented the stones using a mechanical lithotriptor and then the small pieces were removed endoscopically. In summary, Bouveret's syndrome is a rare condition that needs to be treated endoscopically, if possible, using all available techniques including mechanical lithotripsy as many patients are not suitable for a more risky surgical procedure.
Competing interests: None.