Endoscopic therapy of gallstones ileus.

tion of gallstone disease and is primarily treated surgically. We describe three cases of gallstone ileus, including the first report of successful treatment of jejunal gallstone ileus by endoscopically applied electrohydraulic lithotripsy (EHL). A 67−year−old woman was admitted to hospital with epigastric pain. Ultrasonog− raphy showed gallbladder stones and air in the biliary tree. Intestinoscopy detect− ed a stone in the jejunum that occluded the bowel lumen (l" Fig. 1). After unsuc− cessful attempted extraction of the stone using a Dormia basket, EHL was per− formed (Walz Lithotron EL 23 generator; Walz Electronic Inc., Rohrdorf, Germany) using a 4.5 Ch EHL probe (Olympus Op− tical Co. GmbH, Hamburg, Germany), which disintegrated the stone. After this had been done, duodenoscopy and endo− scopic retrograde cholangiopancreatog− raphy (ERCP) showed a cholecystoduode− nal fistula (l" Fig. 2) and the patient un− derwent laparoscopic cholecystectomy. A 71−year−old woman was admitted with postprandial bilious vomiting and ab− dominal pain. Esophagogastroduodenos− copy showed an obstructing gallstone in the bulbus duodeni. Extraction using a Dormia basket failed due to the size of the gallstone. EHL was performed and the stone was fragmented. A 69−year−old woman was admitted with upper abdominal pain. Gastroscopy re− vealed ulcers in the antrum, one of which represented perforation by the gallstone into the antrum, whereby the stone locat− ed in the antrum did not cause an ileus (l" Fig. 3). ERCP demonstrated reflux of contrast medium into the antrum. Me− chanical lithotripsy was successfully per− formed. Cholecystitis often precedes the perfora− tion of the gallstone into the gut forming a cholecystoenteric fistula. The main clin− ical presentation is gastric outlet obstruc− tion of the duodenal bulb (Bouveret’s syndrome). Kasahara et al. reported spon− taneous passage of gallstones in only eight of 112 patients in Japan [1]. Demon− stration of aerobilia by computed tomog− raphy (CT) scan is widely accepted as the preferred imaging method for determin− ing the site of obstruction. Gallstone ileus is normally treated by laparotomy and enterolithotomy [2]. Because of the rela− tively high morbidity and mortality, alter− native procedures to surgery have been suggested. Mechanical lithotripsy [3], EHL [4], and intraluminal laserlithotripsy [5] have been successfully applied. Here we demonstrate the usefulness of thera− peutic endoscopically guided intralumi− nal lithotripsy. Endoscopic therapy of gallstones ileus