A 78-year-old Caucasian (Greek origin) female patient presented with an 8-day history of nausea, multiple bilious vomiting episodes, anorexia, discomfort in the right hypochondrium and epigastrium and fever up to 38,5 C.
 On physical examination the patient was in bad condition with affected facet, pale skin and mucosae, signs of dehydration, tachypnoea, tachyarrhythmia and fever (39 C), while the abdomen was soft, nontender, mildly distended and painful on palpation of the epigastrium and right upper quadrant. 
 Her medical history included a HCV infection, arterial hypertension, chronic atrial fibrillation, diabetes mellitus type 2, stroke with residual left hemiparesis, hypothyroidism, hyperlipidaemia and consumption of NSAIDs over the previous week.
 Laboratory examinations revealed a white blood cell count of 10.72 (x109/L), Neu 88.5%, toxic granulation of polymorphonuclears, a C-reactive protein of 72.7 (IU/L), Glu 139 (IU/L), Urea 73.4 (IU/L), Crea 1.38 (IU/L), gammaGT 87 (IU/L), tBIL 1.37 (IU/L), dBIL 1.10 (IU/L), and LDH 517 (IU/L).
 The chest X-ray revealed a possible aspirational pneumonia. The abdominal X-ray was suspicious for presence of air in the gallbladder (Figure 1).
On abdominal U/S the gallbladder could not be well visualised, the presence of air in the intrahepatic bile ducts was suspected and no dilatation of the bile ducts was detected. The stomach was found dilated and filled with liquid.
Abdominal CT showed the presence of a gallstone in the 2nd to 3rd part of the duodenum and a dilatation of the first part. The presence of contrast and air in the gallbladder was also noticed. The stomach was found with mild dilatation (Figures 2, 3, 4, and 5).
The diagnosis "Bouveret syndrome" was set. A nasogastric tube was placed to decompress the stomach. Initial treatment included administration of fluids, electrolytes and antibiotics.
 For further topographic information a gastrografin meal was performed. A large gallstone was visualised in the 2nd to 3rd part of the duodenum. The gallbladder, the cystic duct and the cholecystoduodenal fistula as well as a duodenal diverticulum of the 3rd part were well visualised (Figures 6 and 7).
The patient was transferred in the endoscopic unit where a gastroduodenoscopy was performed. The fistula orifice was seen (Figure 8) as well as the proximal side of the gallstone (Figure 9). 
Endoscopic removal and mechanical lithotripsy were attempted using different skills and equipment, but all efforts failed (Figure 10). 
Surgical treatment was decided. Due to serious comorbidity the patient received high thoracic epidural anaesthesia. A laparotomy with midline incision was performed. The gallbladder was found collapsed and the cholecystoduodenal fistula was identified. A Kocher's manoeuvre was performed and the gallstone was palpated in the 2nd to 3rd part of the duodenum. An initial effort for proximal removal towards the stomach was unsuccessful. With gentle milking movements distal removal was achieved in the first part of the jejunum right after the ligament of Treitz (Figure 11). No further removal was feasible. A jejunotomy and successful removal of the gallstone were performed (Figure 12). The size of the extracted calculus was 5.8 x 3.7 x 4 cm. The jejunotomy was sutured in two layers. The gallbladder and the fistula were left intact. No other stones were detected in the digestive tract. No complications occurred after surgery and the patient was discharged on the 8th postoperative day.