A 94-year-old patient, allergic to penicillin and its derivatives, with no relevant medical or surgical history, did not take regular medication.
Epigastric abdominal pain with abundant nausea and vomiting of bilious characteristics has occurred in the last 4-5 days.
There were no changes in the depositional rhythm or in the characteristics of the stools.
There is no fever or other associated symptoms.
Physical examination revealed arterial tension 120 mmHg, heart rate 106 bpm, oxygen saturation 96%, FiO2 21%, temperature 36.3oC.
Oriented.
Ligerally lying down.
Normal coloration of skin and mucous membranes
Good distal perfusion.
Eupneic.
Cardiac arrest: cardiac rhythmic noises at 100 beats per minute, systolic murmur pan of predominantly aortic focus.
Pulmonary auscultation revealed normal breath sounds.
Abdomen: blando, deprescribable, non-painful to constipation; non-malignant masses or visceromegaly; not dyssynthetic or dyssynthetic.
Normal peristalsis.
Rectal tract: dedil with normal stool remnants.
Lower extremities without edema or signs of deep venous thrombosis.
After the initial assessment, the following were requested:
- Electrocardiogram: sinus rhythm at 105 bpm, with no changes in repolarisation, depolarisation or conduction disturbances.
- Chest X-ray: normal cardiac silhouette with no acute pleuroparenchymal alterations.
- Blood analysis: hemoglobin 11 mg/dL with hematocrit 35% stands out.
Urea 51 mg/dL with plasma creatinine in normal values.
Medical treatment with fluid therapy and antiemetics was initiated, and upon clinical suspicion of a possible obstructive process of the upper digestive tract against a motor disorder (gastroparesis), it was decided to perform an oral endoscopy.
During the performance of the oral endoscopy, a solid formation of spherical morphology and colorless nodule of about 3 cm in diameter is identified which is enclaved in the duodenum and causes obstruction of the transit at this level.
The patient was diagnosed with gallstone ileus due to biliary stricture (Bouverets anomaly).
The usual treatment of this entity is surgical, but given the advanced age of the patient, it was decided to try endoscopic extraction.
Firstly, duodenum disimpaction was performed by pressing with a loop and then the pylorus could be separated in the opposite direction, and the lithiasis was transported to the stomach.
Once there, lithotripsy maneuvers are performed unsuccessfully.
Subsequently, with a polypectomy loop, the lithiasis was partially introduced into an envelope, as the stone diametro was superior.
The lithiasis was extracted by endoscopy through the oral cavity.
The mucosa of the stomach and duodenum was then reviewed without observing erosions or mucosal lesions.
1.
After extraction of the lithiasis, the clinical picture of the patient is resolved, being asymptomatic.
Analytical and radiographic control was performed without complications and the patient was discharged 24 hours later.
