Endoscopic lithotripsy for Bouveret syndrome complicated by small bowel obstruction secondary to gallstone fragments

Bouveret syndrome is a rare complication of cholecystitis, in which impaction of a gallstone creates a cholecystoduodenal fistula leading to gastric outlet obstruction. We report a case of a 90-year-old female who presented with nausea and vomiting on a background of previous necrotic cholecystitis managed conservatively. Computed tomography of the abdomen demonstrated a large gallstone impacted in the third part of the duodenum leading to gastric outlet obstruction. Given her frailty, the patient underwent endoscopy to relieve the obstruction; however, complete retrieval of the gallstone fragments after lithotripsy was not possible. She subsequently developed distal gallstone ileus due to migration of the gallstone fragments and underwent laparotomy, enterotomy and retrieval of the fragments. This case highlights the dilemma of managing elderly patients with Bouveret syndrome with open or endoscopic surgery and the importance of retrieving all gallstone fragments after lithotripsy to avoid iatrogenic complications, such as gallstone ileus.