Clinical Case Summary

Bouveret syndrome is a rare type of ileus caused by the impaction of large gallstones that pass through a cholecystoenteric fistula in the duodenum.Although endoscopic treatment is preferable over surgery for patients with Bouveret,1 some difficulties in endoscopic procedures must be overcome.2 Herein, we describe the usefulness of combined endoscopic procedures of electrohydraulic lithotripsy (EHL) and new technique by using the guide wire as a snare (Figure1).72 years old female patient known chronic liver disease and splenomegaly came to the emergency department by progressive abdominal pain, persistent vomiting, and weight loss two months ago. Upper Endoscopy was arranged next day and showed hugely dilated stomach with remnant food (signs of Gastric outlet obstruction) down to large stone at second part of duodenum totally obstructing lumen and a fistulous opening. MRCP was done and revealed: dilated Common Bile Duct about 10 mm down to its lower with extensive air in the biliary tree, dilated IHBRs with extensive pneumobilia, collapsed thick-walled gall bladder with air inside and large 35x55 mm impacted stone in the second part of the duodenum. An attempt using Biliary Electrohydraulic lithotripsy (EHL) was done, EHL over 3 hours was with minimal effect as the stone was hard and decreased the stone size to about 4 cm but it is still lodged in the angle, and we couldn’t grasp it by snare.We used Boston scientific guidewire 0.035 to create an open snare which overlapped the stone in its place then gradually pulled to the stomach. Over another 4 hours we used EHL and Lithotripsy stone extractor to destroy the stone into small fragments less than 1 cm.The stone was destroyed. The duodenum was reevaluated and circumferential ulcerations was noted with complete healing of fistula. The patient started oral intake 24 hours after the procedure with no abdominal pain or vomiting. Long term follow up of the patient showed marked weight gain with no adverse effects.

References

1. Cappell MS, Davis M. Characterization of Bouveret’s syndrome: A comprehensive review of 128 cases. A m J G a s t r o e n t e r o l 2006;
101: 2139–46.
2. Caldwell KM, Lee SJ, Leggett PL, Bajwa KS, Mehta SS, Shah SK. Bouveret syndrome: Current management strategies. C l i n E x p
69–75.

Clinical Case Summary

A 67 old male patient with Hx of DM, HTN, IHD and previous repair of paraumbilical hernial defect. He had history of multiple previous ERCP with difficult stone extraction and stent placement to secure biliary drainage.
He presented with fever and abdominal pain mainly at re-herniated defect at paraumbilical region. By examination we found ulcerated skin over the hernial sac with a small foreign body protruding from it. He was sent for radiology and performed abdominal CT examination which commented on a mispositioned/slipped biliary stent along with CBD dilatation. Initial labs showed elevated TLC and bilirubin. he admitted that he neglected the instructions to make an appointment for stent exchange after 3 months as he was told after the last ERCP 2 years ago.
Surgical consultation was done to inspect the ectopic stent, they removed it and recommended for follow up of the fistulous opening only as the CT didn't show serious injuries or any abdominal free fluid.
The ectopic stent was impacted inside an intestinal loop inside the hernial sac and couldn't take the natural pathway out of the body with the excreta.
When we saw the slipped stent that punctured its own way out through the hernia out of the patient's body, we thought that this strange finding was the only surprise that the patient can give us.
Patient was planned for ERCP to secure biliary drainage.
After cannulation while performing ERCP, the cholangiogram revealed another surprise, The patient had another hidden stent, an internally migrated one.
It was removed by balloon sweeping and another new double pigtail stent was inserted to ensure more stability.
Upon our request we brought the previous ERCP reports to be revised. We found that the last procedure 2 years ago reported a missed stent already and he put a new one. This means that the hernial stent was the older slipped one and kept in place for this whole time till it decided to get out and the newer stent was internally migrated.