Effective endoscopic holmium laser lithotripsy in the treatment of a large impacted gallstone in the duodenum

Gallstone ileus is caused by the passage of one or more large gallstones (at least 2.5 cm in size) in the gastrointestinal tract through a bilioenteric fistula. It accounts for 1 % to 4 % of all cases of mechanical small-bowel obstruction [1] [2]. The obstructing gallstone is usually impacted in the terminal ileum, rarely the duodenum [1]. Computed tomography generally reveals mechanical bowel obstruction, pneumobilia, and an ectopic stone in the intestinal lumen (Rigler’s triad) [3]. Although surgery is considered the gold standard treatment, a less invasive endoscopic approach is advisable in high risk patients [4].

An 87-year-old woman was admitted to the emergency department with abdominal pain and vomiting of 3 days’ duration. Computed tomography showed a large, calcified ring in the duodenum and aerobilia ([Fig. 1]). Upper gastrointestinal endoscopy revealed a large obstructive stone in the duodenal bulb that could not be removed endoscopically, even after pyloric dilation. Because of the obstructive symptoms, a gastrojejunal anastomosis was created, which partially relieved the obstruction.

Fig. 1 Computed tomographic scan shows a large calcified ring (stone) in the duodenum of an 87-year-old woman presenting with abdominal pain and vomiting of 3 days’ duration.

To fragment the stone, we performed another endoscopic procedure. A holmium laser (HLS30 W Holmium:YAG 30 W Laser; Olympus America, Center Valley, Pennsylvania, USA) was applied for a total of approximately 200 minutes. This resulted in fragmentation of the stone into small parts, which were removed with an extraction basket and a retrieval device ([Video 1]).

Endoscopic holmium laser lithotripsy treatment of a large impacted gallstone in the duodenum.

The patient was discharged after 15 days with complete resolution of the occlusive symptoms, and her scheduled cholecystectomy was canceled.

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• References

• 1 Reisner RM, Cohen JR. Gallstone ileus: a review of 1001 reported cases. Am Surg 1994; 60: 441-446
• 2 Rodriguez H, Codina C, Girones V et al. Gallstone ileus: results of analysis of a series of 40 patients. Gastroenterol Hepatol 2001; 24: 489-494
• 3 Rigler LG, Borman CN, Noble JF. Gallstone obstruction: pathogenesis and roentgen manifestations. JAMA 1941; 117: 1753-1759
• 4 Goldstein EB, Savel RH, Pachter HL et al. Successful treatment of Bouveret syndrome using holmium: YAG laser lithotripsy. Am Surg 2005; 71: 882-885