Patient aged 94 years, allergic to penicillin and derivatives, with no medical or surgical history of interest, who does not take regular medication. She reported that in the last 4-5 days she had presented episodes of epigastric abdominal pain with nausea and abundant vomiting with bilious characteristics, for which reason she came to the emergency department. There have been no alterations in stool rhythm or stool characteristics. There was no fever or other associated symptoms.
Physical examination: blood pressure 120/80 mmHg, heart rate 106 bpm, O2 saturation 96% with FiO2 21%, temperature 36.3o C. Conscious. Orientation. Slightly dehydrated. Normal colour of skin and mucous membranes. Good distal perfusion. Eupneic. Cardiac auscultation: rhythmic heart sounds at 100 bpm, panfocal systolic murmur predominantly in aortic focus. Pulmonary auscultation: normal vesicular murmur. Abdomen: soft, depressible, not painful on palpation; no masses or visceromegaly, no distension or tympanism. Normal peristalsis. Rectal examination: normal stool remains in the rectum. Lower extremities without oedema or signs of deep vein thrombosis.
After the initial assessment, the following was requested:
- Electrocardiogram: sinus rhythm at 105 bpm, without repolarisation, depolarisation or conduction disturbances.
- Chest X-ray: normal cardiac silhouette with no acute pleuroparenchymal alterations.
- Blood tests: haemoglobin 11 mg/dL with haematocrit 35%. Urea 51 mg/dL with plasma creatinine in normal values.
Medical treatment was started with fluid therapy and antiemetics, and given clinical suspicion of a possible obstructive process of the upper digestive tract as opposed to a motor disorder (gastroparesis), it was decided to perform an oral endoscopy.
During the oral endoscopy, a solid formation of spherical morphology and yellowish colouring of about 3 centimetres in diameter was identified, which was embedded in the duodenum and caused obstruction of transit at this level. The patient was diagnosed with biliary ileus due to lithiasis lodged in the duodenum (Bouveret's syndrome). The usual treatment for this entity is surgical, but given the advanced age of the patient, it was decided to try endoscopic extraction. First of all, the duodenum was disimpacted, using a net loop, and then the pylorus was crossed in the opposite direction, and the lithiasis was transported to the stomach. Once there, lithotripsy manoeuvres are carried out without success. Subsequently, a polypectomy loop was used to partially introduce the lithiasis into an overtube, as the diameter of the lithiasis was larger. The lithiasis was extracted endoscopically through the oral cavity. Subsequently, the mucosa of the stomach and duodenum was examined without observing any erosions or mucosal lesions.

After removal of the lithiasis, the patient's clinical picture was resolved and she was asymptomatic. She underwent analytical and radiographic control without complications and was discharged from hospital after 24 hours.

