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Successful endoscopic treatment of Bouveret's syndrome with intracorporeal electrohydraulic lithotripsy
At the Focal Point
Successful endoscopic treatment of Bouveret’s syndrome with intracorporeal electrohydraulic lithotripsy
An 84-year-old man presented with repeated coffee ground emesis. Upper endoscopy revealed a large gallstone impacted in the duodenal bulb (A), prohibiting passage of the endoscope downstream. MRCP demonstrated a cholecystoduodenal fistula and a 3-cm gallstone in the duodenal bulb (Bouveret’s syndrome). Because of the size and location of the stone, fragmentation with mechanical lithotripsy was not feasible. Therefore, we used intracorporeal endoscopic electrohydraulic lithotripsy (Northgate Technologies, Inc, Arlington Heights, Ill) with a Micro II
1.9F lithotripsy probe (B) at a setting of 70 to 100 watts to successfully fracture the stone into small fragments (C). The patient improved clinically, and follow-up endoscopy showed no remaining stone fragments. A 69-year-old man presented with right upper–quadrant pain, nausea, and vomiting. Abdominal CT showed extravasation of oral contrast from the duodenum, and a round filling defect was demonstrated in the proximal duodenum on upper GI series (D). Endoscopy revealed a 3-cm gallstone impacted in the duodenal bulb. Intracorporeal
www.giejournal.org
Volume 66, No. 1 : 2007 GASTROINTESTINAL ENDOSCOPY 183
At the Focal Point
endoscopic electrohydraulic lithotripsy was performed at 70 to 90 watts with successful stone fragmentation, exposing an opening to a fistulous tract in the duodenal bulb. The patient improved clinically and was discharged.
Elizabeth S. Huebner, MD, Suja DuBois, MD, Scott D. Lee, MD, Michael D. Saunders, MD, Division of Gastroenterology, University of Washington School of Medicine, Seattle, Washington, USA
DISCLOSURE The authors have no disclosures to make.
doi:10.1016/j.gie.2007.01.024
Commentary Leon Bouveret described not only gastric outlet obstruction from an impacted gallstone (Bouveret’s syndrome I) but also paroxysmal supraventricular tachycardias (Bouveret syndrome II). He was known to enthusiastically support new surgical methods, and likely would have appreciated the authors’ use of electrohydraulic lithotripsy, in which shear forces and cavitation bubbles are created to fragment large stones into smaller pieces that are then easily passed downstream or removed at endoscopy or surgery. Dr Bouveret also is known for his timeless quote: ‘‘Physicians are there for their patients, not for their own careers.’’ I do think, however, he would not have minded were one to simultaneously advance both causes. Lawrence J. Brandt, MD Associate Editor for Focal Points
Double-balloon endoscopy for jejunal hemangioma (with video)
184 GASTROINTESTINAL ENDOSCOPY Volume 66, No. 1 : 2007
www.giejournal.org
Successful endoscopic treatment of Bouveret’s syndrome with intracorporeal electrohydraulic lithotripsy
An 84-year-old man presented with repeated coffee ground emesis. Upper endoscopy revealed a large gallstone impacted in the duodenal bulb (A), prohibiting passage of the endoscope downstream. MRCP demonstrated a cholecystoduodenal fistula and a 3-cm gallstone in the duodenal bulb (Bouveret’s syndrome). Because of the size and location of the stone, fragmentation with mechanical lithotripsy was not feasible. Therefore, we used intracorporeal endoscopic electrohydraulic lithotripsy (Northgate Technologies, Inc, Arlington Heights, Ill) with a Micro II
1.9F lithotripsy probe (B) at a setting of 70 to 100 watts to successfully fracture the stone into small fragments (C). The patient improved clinically, and follow-up endoscopy showed no remaining stone fragments. A 69-year-old man presented with right upper–quadrant pain, nausea, and vomiting. Abdominal CT showed extravasation of oral contrast from the duodenum, and a round filling defect was demonstrated in the proximal duodenum on upper GI series (D). Endoscopy revealed a 3-cm gallstone impacted in the duodenal bulb. Intracorporeal
www.giejournal.org
Volume 66, No. 1 : 2007 GASTROINTESTINAL ENDOSCOPY 183
At the Focal Point
endoscopic electrohydraulic lithotripsy was performed at 70 to 90 watts with successful stone fragmentation, exposing an opening to a fistulous tract in the duodenal bulb. The patient improved clinically and was discharged.
Elizabeth S. Huebner, MD, Suja DuBois, MD, Scott D. Lee, MD, Michael D. Saunders, MD, Division of Gastroenterology, University of Washington School of Medicine, Seattle, Washington, USA
DISCLOSURE The authors have no disclosures to make.
doi:10.1016/j.gie.2007.01.024
Commentary Leon Bouveret described not only gastric outlet obstruction from an impacted gallstone (Bouveret’s syndrome I) but also paroxysmal supraventricular tachycardias (Bouveret syndrome II). He was known to enthusiastically support new surgical methods, and likely would have appreciated the authors’ use of electrohydraulic lithotripsy, in which shear forces and cavitation bubbles are created to fragment large stones into smaller pieces that are then easily passed downstream or removed at endoscopy or surgery. Dr Bouveret also is known for his timeless quote: ‘‘Physicians are there for their patients, not for their own careers.’’ I do think, however, he would not have minded were one to simultaneously advance both causes. Lawrence J. Brandt, MD Associate Editor for Focal Points
Double-balloon endoscopy for jejunal hemangioma (with video)
184 GASTROINTESTINAL ENDOSCOPY Volume 66, No. 1 : 2007
www.giejournal.org