Successful Endoscopic Management of Bouveret Syndrome by Transpyloric Stone Relocation and Intragastric Mechanical Lithotripsy

Background: Bouveret syndrome is a rare form of gallstone ileus in which a gallstone migrates through a bilioenteric fistula and impacts at the gastric outlet or proximal duodenum. It affects predominantly frail elderly women, in whom an endoscopy-first strategy is desirable; however, complete endoscopic clearance is achieved in fewer than half of cases and becomes markedly less likely as stone size increases, meaning that large stones often prompt surgery. Case Presentation: A 95-year-old woman presented with four days of vomiting and obstipation. Computed tomography demonstrated gastric outlet obstruction caused by a large gallstone impacted in the duodenal bulb with pneumobilia, consistent with Bouveret syndrome. Owing to her advanced age and operative risk, an entirely endoscopic approach was pursued. Initial extraction within the duodenal bulb using a retrieval net and foreign-body forceps failed because neither device could engage the stone. The closed forceps were therefore used as a lever to rotate and mobilize the stone until complete capture with the retrieval net became possible, after which the 37 mm stone was relocated through the pylorus into the stomach under controlled traction. As intact transoral extraction remained impossible, intragastric mechanical lithotripsy was performed and all fragments were retrieved transorally, achieving complete endoscopic clearance without surgery. The post-procedural course was uneventful; oral intake was resumed the following day, and the patient was discharged in good condition. Conclusions: Relocation of an impacted gallstone into the stomach before mechanical lithotripsy has been described previously. In this case, the stone could not initially be engaged; closed forceps used as a lever to rotate and mobilize it made capture with a retrieval net, and thus relocation, possible. This step allowed for complete endoscopic clearance without surgery in this single high-risk patient; its wider applicability remains to be established.