Bouveret Syndrome: the stone that broke the camel's back (and stomach)

History A 76-year-old woman was hospitalized because of increasing pain in the upper abdomen, nausea and non-bilious vomiting. A normal food intake had been impossible for one week. She had a medical history of a biliary necrotizing pancreatitis five years ago. The patient had refused to undergo cholecystectomy in the past. Examinations Physical examination showed a pain during palpation of the right upper abdomen. The abdominal ultrasonography raised the suspicion of a gastric outlet obstruction, which was confirmed by gastroscopy showing an occlusion of the pylorus by a foreign object. In a consecutively performed re-gastroscopy the suspicious object turned out to be a huge gallstone that had slipped into the gastric corpus spontaneously. Treatment The outlet obstruction was resolved by spontaneous transfer of the gallstone from the pylorus to the stomach. Due to the size of the stone we had to perform a mechanical lithotripsy within the stomach. Afterwards all fragments were salvaged. Conclusion Bouveret syndrome is a rare form of gallstone ileus. Besides gastroscopy, contrast-enhanced computer tomography should be first choice of medical imaging. Primary goal of all intervention is the removal of the obstructing gallstone. Endoscopy is the treatment of choice. Additional surgery is debatable and remain an individual decision. However, it should be performed as a two-stage procedure or not at all.