# Minimally Invasive Management of Gastric Outlet Obstruction Secondary to Cholecystogastric Fistula With Gallstone Impaction: A Case Report

## TL;DR

A 63-year-old patient with a rare gallstone complication was successfully treated using minimally invasive techniques when surgery was not an option.

## Contribution

Demonstrates the use of minimally invasive endoscopic methods for managing gastric outlet obstruction in a high-risk patient.

## Key findings

- Conversion of a G-tube to a GJ-tube improved feeding and symptoms.
- Endoscopic lithotripsy fragmented the gallstone, though complete removal required follow-up.
- Minimally invasive techniques provided effective management for a non-surgical candidate.

## Abstract

Cholecystogastric fistulas are rare complications of gallstone disease that can lead to significant clinical scenarios, one of which is gastric outlet obstruction. This case underscores the utility of minimally invasive techniques in managing biliary conditions.

We present a case of a 63-year-old female Jehovah’s Witness with a significant medical history, including iron and B12 deficiency anemia, chronic gallstone disease, and squamous cell carcinoma of the hypopharynx, who presented with severe abdominal pain and nausea. Diagnostic imaging revealed a cholecystogastric fistula with a large gallstone causing gastric outlet obstruction. The patient was deemed a non-surgical candidate. Conventional endoscopy was not an option either, given the history of a high-grade hypopharyngeal stricture from prior cancer treatment. Multiple minimally invasive procedures were performed, including the conversion of a gastrostomy tube (G-tube) to a gastrojejunostomy tube (GJ-tube), and percutaneous endoscopic lithotripsy using the SpyGlass system (Boston Scientific Corporation, Marlborough, MA, USA).

The initial conversion of the G-tube to a GJ-tube improved feeding tolerance and provided symptomatic relief. Endoscopic lithotripsy successfully fragmented the gallstone, although complete removal was not achieved in the first session. The patient’s condition improved, with reduced abdominal pain and better nutritional management, and further follow-up procedures were planned to address the residual stone.

This case illustrates the effectiveness of minimally invasive techniques, such as endoscopic lithotripsy, in managing complex biliary conditions. These approaches are especially critical for patients who are poor surgical candidates or refuse blood products, as surgical intervention poses heightened risks in managing potential hemorrhagic complications.