Bouveret''s syndrome was first described by Bartolin in the 17th century as disease of elderly and debilitated people. In the 19th century, French physician Leon Bouveret described a syndrome of gastric outlet obstruction – caused by an impacted gallstone in the duodenal bulb after migration through a cholecysto- or choledocho-duodenal fistula.
A 93 years old female patient was referred to our department presenting with the following symptoms:
- Occasional abdominal pain
- She tolerated the intake of liquid meals and drinks, but no solid food.
- Furthermore, she suffered from weight loss about 20 pounds in six months.
Important co-morbidities of this elderly patient to be mentioned:
- Parkinson''s disease
During upper GI-endoscopy we found a large stone in the duodenal bulb leading to a subtotal stenosis. We were not able to pass by this concrement to reach the descending duodenum. This large stone of very hard consistency was suspicious of a penetrated gallstone. Because of its size we had no therapeutic option of removal by endoscopic means.
To provide a disintegration of the stone we performed an extracorporeal shock wave lithotripsy (ESWL). We placed a nasal-duodenal tube for applying contrast medium for better demarcation.
In five sessions of ESWL, we applied 1000 hits of 13-16 kV, 16-18 kV, 19 kV each. Post-interventionally we found a clear disintegration of the gallstone similar to a stone pit.
Only small parts of the large concrement could be extracted successfully. However, we were not able to substantially remove the obstacle in the duodenal bulb.
How to proceed further?
After this unsuccessful therapeutic approach using ESWL, we decided to apply laser therapy, using Holmium YAG Laser, by Karl Storz Endoscopy, Germany, with an energy of 9.6 Joule.
Like an air hammer the tip of the laser probe drills into the concrement and is able to crack it eventually.
After a time interval of 24 hours and another session of laser lithotripsy we were able to extract several large stone fragments by dormia basket.
After successful laser lithotripsy all obstacles were removed. Upper GI-endoscopy revealed the porus in the duodenal bulb of the choledocho-duodenal fistula. The passage to the descending duodenum is clear now.
MRCP showed a concrement-free bile duct system.
The combination of extracorporeal shock wave and laser lithotripsy may be successful for therapy of Bouveret''s syndrome. One may speculate whether laser lithotripsy by itself might have been sufficient. After successful endoscopic therapy surgery could be avoided for this old lady.
Dirk Domagk, MD, University of Muenster
Philip Lenz, M.D., University of Muenster
Christian Wulfing, MD, University of Muenster
Thorsten Pohle, MD, University of Muenster
Wolfram Domschke, MD, University of Muenster
Torsten Kucharzik, MD, University of Muenster