Gastrointestinal hemorrhage associated with gallstone ileus from an impacted gallstone in the duodenum originating from a cholecystoduodenal fistula is a rare presenting symptom of Bouveret's syndrome [1-4]. The treatment in these cases was surgical removal of the gallstone. Endoscopy has offered a minimally invasive treatment modality in Bouveret's syndrome, which typically affects elderly patients with multiple comorbidities [5-7]. This video demonstrates an endoscopic approach to managing Bouveret's syndrome that presents with gastrointestinal hemorrhage. Methods: Patient is a 78 year old male with several comorbidities including Parkinson's Disease with multi-system atrophy and severe dysphagia requiring PEG tube presented with acute onset of abdominal pain and coffee-ground emesis. Esophagogastroduodenoscopy was performed and identified a large partially obstructing gallstone at the duodenal bulb and pylorus. Computed Tomography demonstrates pneumobilia and the findings were suggestive of Bouveret's syndrome, an obstructing gallstone in the duodenum resulting from a cholecystoduodenal fistula. Video presents endoscopic management of a large gallstone lodged in the duodenum. Morcellation of the large stone was performed with an endoscopic mechanical lithotripter due to inability to pass through the pylorus. Large fragments were retrieved with an endoscopic basket, while other remnants passed through small bowel. The underlying duodenal ulcer was managed medically. Results: Patient had resolution of gastrointestinal bleed and remains without signs of obstruction. There are no future plans for cholecystectomy or operation at this time since the patient is a high risk surgical candidate and most cholecystoduodenal fistulae resolve spontaneously.