A novel method of lithotripsy of a large luminal bezoar stone by use of an ERCP guidewire

A 69-year-old woman was admitted for gastric outlet obstruction resulting from a >5 cm bezoar stone in the duodenum, causing obstruction observed on CT (A). A >3 cm oval snare failed to grab the stone because of its large size. Laser lithotripsy and electrohydraulic lithotripsy equipment was not available. We created a novel snare-like lithotripsy device by using an ERCP guidewire as follows: (1) we cut and removed the over-sheath catheter from a snare, (2) passed the catheter down the duodenoscope with the tip reaching the rim of the clean cap, and (3) folded a 460-cm 0.035-inch ERCP guidewire and passed both ends of the wire down the catheter lumen from the camera end, forming an adjustable snare device (B). We then advanced the EGD duodenoscope to the bezoar. After the bezoar was encircled by the loop, lithotripsy was done by pulling both ends of the guidewire back forcibly (C). The large bezoar was fragmented and then removed (D).