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Successful Multimodality Endoscopic Treatment of Gastric Outlet Obstruction Caused by an Impacted Gallstone (Bouveret's Syndrome).

Rogart JN, Perkal M, Nagar A - Diagn Ther Endosc (2008)

Bottom Line: Due to the large size of these stones and the difficult location in which they become impacted, endoscopic treatment is unsuccessful and most patients require surgery.After several endoscopic sessions and the use of multiple instruments including a Holmium: YAG laser and electrohydraulic lithotripter, fragmentation and endoscopic removal of the stone were successful.We describe the difficulties encountered which necessitated varied and innovative therapeutic techniques.

View Article: PubMed Central - PubMed

Affiliation: Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, West Haven VAMC, CT 06510, USA.

ABSTRACT
Bouveret's syndrome is a rare condition of gastric outlet obstruction resulting from the migration of a gallstone through a choledochoduodenal fistula. Due to the large size of these stones and the difficult location in which they become impacted, endoscopic treatment is unsuccessful and most patients require surgery. We report the case of an elderly male who presented with nausea and hematemesis, and was found on CT scan and endoscopy to have an obstructing gallstone in his duodenal bulb. After several endoscopic sessions and the use of multiple instruments including a Holmium: YAG laser and electrohydraulic lithotripter, fragmentation and endoscopic removal of the stone were successful. We believe this to be the first case of Bouveret's syndrome successfully treated by endoscopy alone in the United States. We describe the difficulties encountered which necessitated varied and innovative therapeutic techniques.

No MeSH data available.


Related in: MedlinePlus

The largest stone fragments were removed perorally. The inner composition of the largest piececan be seen, measuring greater than 1 cm in diameter.
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fig6: The largest stone fragments were removed perorally. The inner composition of the largest piececan be seen, measuring greater than 1 cm in diameter.

Mentions: On repeat endoscopy, the largeststone fragment had again become impacted in the duodenal bulb, but wasextracted by placing a biliary balloon behind it and a polypectomy snare aroundits center. In the stomach, the largeststones could not be crushed despite use of a mechanical lithotripter. Tofurther break up the stones, we used the Holmium: YAG laser (1000-micron fiber for 128 joules for 427 pulsesper second for a total delivery time of 2 minutes and 49 seconds) to bore multipleholes into the center of each fragment, which was then crushed with a biliary stonebasket. The larger fragments wereremoved perorally (see Figure 6) with a Roth net (US Endoscopy, Ohio, USA), whilethe very small pieces were left behind to pass spontaneously. Two weeks later, a fourth endoscopy wasperformed to place a gastrostomy feeding tube, and no residual stones were seenin the stomach or duodenum. Additionally,the orifice of the cholecystoduodenal fistula was significantly smaller. Two months later, the patient remained asymptomatic.


Successful Multimodality Endoscopic Treatment of Gastric Outlet Obstruction Caused by an Impacted Gallstone (Bouveret's Syndrome).

Rogart JN, Perkal M, Nagar A - Diagn Ther Endosc (2008)

The largest stone fragments were removed perorally. The inner composition of the largest piececan be seen, measuring greater than 1 cm in diameter.
© Copyright Policy - open-access
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC2239211&req=5

fig6: The largest stone fragments were removed perorally. The inner composition of the largest piececan be seen, measuring greater than 1 cm in diameter.
Mentions: On repeat endoscopy, the largeststone fragment had again become impacted in the duodenal bulb, but wasextracted by placing a biliary balloon behind it and a polypectomy snare aroundits center. In the stomach, the largeststones could not be crushed despite use of a mechanical lithotripter. Tofurther break up the stones, we used the Holmium: YAG laser (1000-micron fiber for 128 joules for 427 pulsesper second for a total delivery time of 2 minutes and 49 seconds) to bore multipleholes into the center of each fragment, which was then crushed with a biliary stonebasket. The larger fragments wereremoved perorally (see Figure 6) with a Roth net (US Endoscopy, Ohio, USA), whilethe very small pieces were left behind to pass spontaneously. Two weeks later, a fourth endoscopy wasperformed to place a gastrostomy feeding tube, and no residual stones were seenin the stomach or duodenum. Additionally,the orifice of the cholecystoduodenal fistula was significantly smaller. Two months later, the patient remained asymptomatic.

Bottom Line: Due to the large size of these stones and the difficult location in which they become impacted, endoscopic treatment is unsuccessful and most patients require surgery.After several endoscopic sessions and the use of multiple instruments including a Holmium: YAG laser and electrohydraulic lithotripter, fragmentation and endoscopic removal of the stone were successful.We describe the difficulties encountered which necessitated varied and innovative therapeutic techniques.

View Article: PubMed Central - PubMed

Affiliation: Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, West Haven VAMC, CT 06510, USA.

ABSTRACT
Bouveret's syndrome is a rare condition of gastric outlet obstruction resulting from the migration of a gallstone through a choledochoduodenal fistula. Due to the large size of these stones and the difficult location in which they become impacted, endoscopic treatment is unsuccessful and most patients require surgery. We report the case of an elderly male who presented with nausea and hematemesis, and was found on CT scan and endoscopy to have an obstructing gallstone in his duodenal bulb. After several endoscopic sessions and the use of multiple instruments including a Holmium: YAG laser and electrohydraulic lithotripter, fragmentation and endoscopic removal of the stone were successful. We believe this to be the first case of Bouveret's syndrome successfully treated by endoscopy alone in the United States. We describe the difficulties encountered which necessitated varied and innovative therapeutic techniques.

No MeSH data available.


Related in: MedlinePlus