Gastric Outlet Obstruction by a Large Gallstone (Bouveret’s Syndrome)

Bouveret’s syndrome is an uncommon cause of gastric outlet obstruction due to intraluminal duodenal obstruction by a large gallstone, which has migrated via a cholecystoduodenal fistula. The presenting symptoms are not specific in the majority of cases, but most of the patients have known biliary lithiasis. Usually Bouveret’s syndrome carries a poor prognosis. Consideration of Bouveret’s syndrome in patients presenting with gastric outlet obstruction is important because of the rarity of this entity and the difference in the required surgical approach from that applied for other more common causes of obstruction. We present the case of a 55-year-old male with Bouveret’s syndrome, presenting as the first manifestation of gallstone disease, and successfully treated by open surgery, with a comprehensive literature review.     

A Rare Variant of Gallstone Ileus: Bouveret’s Syndrome

Introduction

Bouveret’s syndrome (gastric outlet obstruction due to impaction of a stone) is a rare variant of gallstone ileus. A recently observed case led us to review the literature, with the aim to discuss the recent advances in the management of this rare syndrome.

Discussion

A 69-year-old woman was admitted with symptoms of high intestinal obstruction. Computed tomography scan of the abdomen showed a large gallstone impacted in the duodenum. One-stage surgery, consisting in enterolithotomy, cholecystectomy, and fistula repair, was carried out. Although several surgical and nonoperative procedures have been used, the optimal treatment of Bouveret’s syndrome remains controversial. Surgery still maintains a prominent position, even though nonoperative procedures have an increasing role especially in high risk patients with important comorbidities. The decision should be taken on an individual basis, after evaluating patient’s general condition and age, stone size, comorbidities influencing the operative risk, and expertise of surgical and endoscopic teams. One-stage surgery may offer definitive management in selected patients.     

Carcinoma Gall Bladder with Bouveret’s Syndrome: A Rare Cause of Gastric Outlet Obstruction

We describe a case of bouveret’s syndrome associated with carcinoma gall bladder. This is probably the second reported case of such an association. Computed tomography detected the calculus in the duodenum but endoscopy could not retrieve it. Open gastrojejunostomy and stone retrieval was done.     

Gallstone Ileus in a Patient with Crohn’s Disease: a Case Report

Gallstone ileus is a rare complication of cholelithiasis. Only 0,3–0,5% of all patients with gallstones will eventually suffer from this condition. It is well known that there is an increased prevalence of gallstones among patients with Crohn’s disease, but gallstone ileus remains even in these patients an unfrequent condition. Because of the rarity of this disease and its presentation as an intestinal (sub)obstruction, mostly without biliary symptoms, diagnosis and surgical treatment are often delayed. We report the case of a 75-year-old woman with a long history of Crohn’s disease presenting with intermittent symptoms of intestinal obstruction since several weeks. Symptoms were thought to be due to recurrence of Crohn’s disease, but the patient did not respond to steroid therapy. Resection of the diseased ileocolic segment was performed and a large impacted stone was detected proximal of the stenotic segment. With this case report we want to emphasize how easily diagnosis of gallstone ileus can be missed, especially in Crohn’s patients and we would like to discuss the different treatment options.     

Gastric Antral Vascular Ectasia — An Unusual Cause of Gastric Outlet Obstruction: Report of a Case

Gastric antral vascular ectasia is an important cause of gastric bleeding. We herein report a case of gastric outlet syndrome due to a gastric antral vascular ectasia in a patient with a negative history for anemia or gastric bleeding. The patient underwent an antral resection. The specimen showed vascular ectasia, fibromuscular hyperplasia, and fibrin thrombosis, especially localized in the submucosa. The pathogenesis of this syndrome remains unclear. Surgery in cases of gastric outlet obstruction is the only reliable method to cure the patient. An antrectomy has been shown to be the procedure of choice. It carries a remarkably low rate of long-term sequelae and it can be performed in the majority of cases with low risk, especially in those patients not affected by cirrhosis or portal hypertension.     

Case Report: a Rare Case of Amyand’s Hernia Presenting in a 3-year-old Male Child

The finding of the vermiform appendix in an inguinal hernia has an incidence of approximately 1 %. The condition is given the eponymous name “Amyand’s hernia.” However, in just 0.08 %, the condition is complicated by an acute appendicitis. The clinical presentation varies, depending on the extent of inflammation of the appendix, and is most often misdiagnosed as an incarcerated inguinal hernia. As such, it is rarely recognized prior to surgical exploration. We report a case of Amyand’s hernia in a 3-year-old child who presented as a right-sided congenital hernia with pain in the right groin. He underwent herniotomy, which revealed that the hernia sac containing elongated inflamed appendix appeared with some adhesions to sac, lying in the inguinal canal.     

Colonic Volvulus Associated with Chilaiditi’s Syndrome: Report of a Case

Hepatodiaphragmatic interposition of the intestine, known as Chilaiditis syndrome, is a rare and often asymptomatic anomaly, typically found as an incidental radiographic sign. We report a case of Chilaiditis syndrome associated with transverse colon volvulus, predisposed by segmental agenesis of the right lobe of the liver. A 45-year-old man presented with a 2-day history of abdominal pain, nausea, vomiting, and constipation. Plain chest X-ray and abdominal computed tomography showed colonic interposition and segmental agenesis of the right lobe of the liver. Laparotomy revealed a clockwise volvulus of the transverse colon associated with interposition and incarceration of the colon through the space of the agenetic segment of the liver. The transverse colon, which was adherent to the agenetic space in the liver and diaphragm, was dissected away and repositioned, and the volvulus was reduced. To our knowledge, this is only the sixth reported case of a colonic volvulus associated with Chilaiditis syndrome and the first case associated with segmental agenesis of the right lobe of the liver.     

Gallstone obstructing the duodenum. Report of two cases of Bouveret’s syndrome

Bouveret’s syndrome is the obstruction of the duodenum due to a gallstone. It is a rare condition, known for over a century that continues to confound emergency room physicians and surgeons to this day. We present two cases of Bouveret’s syndrome. The first is a 63-year-old female patient with a 4 cm gallstone obstructing the third part of the duodenum. The patient underwent prompt surgery and the gallstone was removed through the jejunum. The other patient’s course, an 88–year-old male, was more complicated. After fluid resuscitation and an attempt at endoscopic removal, a gallstone obstructing the first part of the duodenum was surgically removed through a gastrotomy. Both patients recovered fully and were discharged. Both cases presented many dilemmas and challenges from the diagnosis to the final management.     

Mesenteric Meckel’s Diverticulum: a Case Report

Meckel’s diverticulum, an omphalomesenteric remnant caused by the failure of the vitelline duct to involute by the seventh or eight week of gestation, was first described in 1809 by Johann Friederick Meckel. It is the most common congenital abnormality of the small intestine. It is usually located in the last 90 cm of the terminal ileum and is formed by all layers of the small intestine. It frequently contains heterotopic tissue, usually gastric mucosa. Here we report a 15-year-old white female who presented to the emergency ward with abdominal pain. Laparatomy was performed with the diagnosis of acute abdomen. A Meckel’s diverticulum was found in the mesenteric aspect of the ileum. Histologic examination of the specimen revealed the presence of pancreatic tissue and oxyntic and antral type gastric mucosa showing chronic peptic ulceration apart from intestinal mucosa. This case report underlines the need for a revision in our understanding and classification of Meckel’s diverticulum.     

Küttner’s Tumour: a Case Report

Küttner’s tumour (chronic sclerosing sialadenitis) is a chronic inflammatory disease of the salivary glands. It is a totally benign lesion. However, because of its clinical features, the clinical diagnosis is often that of a salivary gland neoplasm.

We present a case of unilateral Küttner’s tumour in the left submandibular salivary gland and discuss clinical, imaging and histological features.     

Enteroliths in Crohn’s Disease: a Case Report

Subtraction angiography is an invasive diagnostic method, which for a long time was a gold standard in carotid artery and intra-cranial vessel imaging. The aim of this research is to evaluate angiographic imaging in predicting atherosclerotic plaque type VI by AHA morphology and to assess its significance in establishing patients’ suitability for a particular operative method. Secondarily, we assessed atherosclerotic lesions in common carotid artery bifurcation. In the paper we analyzed 158 bilateral angiograms of common and internal carotid arteries in extra-and intra-cranial locations.

The material consisted of patients hospitalized in the Vascular Surgery Ward of Memorial Copernicus Hospital in Lodz during 2002–2004 who underwent angiography. We concluded that: 1. In symptomatic patients irregular plaque images in subtraction angiography is correlated with plaque type VI by AHA morphology. 2. Angiography is not a sufficient method for selection of the appropriate operative treatment due to its low sensitivity and specificity in plaque morphology imaging. 3. Plaque type VI by AHA is characteristic even for the second group of carotid bifurcation stenosis (by NASCET) and it definitely dominates in group III (by NASCET).     

Laparoscopic Treatment of Boerhaave’s Syndrome: a Case Report and Review of the Literature

Spontaneous rupture of the oesophagus (Boerhaave’s syndrome) is a rare life-threatening disease requiring urgent surgical management. Symptoms can masquerade many other clinical disorders like acute myocardial infarction, dissecting aneurysm or upper gastro-intestinal tract diseases. Without prompt diagnosis and treatment, Boerhaave’s syndrome has a very high mortality rate.

We report a case of perforation of the distal oesophagus. A 40-year-old male patient presented at the emergency department with a classic history of acute epigastric pain and dyspnoea after an episode of vomiting. On clinical examination we found a firm, tender abdomen and cervical subcutaneous emphysema. Boerhaave’s syndrome was suspected on a clinical basis and was confirmed by thoraco-abdominal CT scan, showing an apparent pneumomediastinum and fluid at both lung bases. The patient underwent surgical repair of the distal oesophageal tear by laparoscopy. A mediastinal drain was left behind and a feeding gastrostomy was established. After initial improvement, the patient developed fever and dyspnoea. A thoracic CT scan revealed left-sided empyema. A thoracoscopic drainage of pus was performed and antibacterial and antifungal treatment was adapted. The patient recovered well and was discharged from the hospital 34 days after admission.     

Lemierre’s Syndrome Associated with Septic Pulmonary Embolism: A Case Report

An 18-year-old female patient suffering from a painful right-sided neck mass was admitted to our emergency service. Computed tomography of the neck revealed thrombosis of the right internal jugular vein. Computed tomography of the chest indicated septic pulmonary emboli in both lungs. Blood and oropharyngeal cultures showed proteus that was sensitive to cefepime and amicasin. Chemotherapy was administered for 12 days, however, her complaints continued with fulminant progression. An urgent decompression and excessive debridement were performed. Although Lemierre syndrome is a well-known cause of internal jugular vein thrombosis, association with proteus culture is very rare.     

Jarcho’s Syndrome: Bone Marrow Infiltrates from a Gastric Malignancy

Bone and bone marrow metastasis is extremely rare in adenocarcinoma particularly from the stomach. We present a case of gastric carcinoma primarily manifesting as anemia and pancytopenia. On evaluation, he was found to have bone marrow secondaries from a gastric primary tumor. Though such metastasis is rare, patients with refractory anemia must be evaluated to search for solid organ malignancy like the stomach.     

Aortobifemoral Graft Causing Complete Intestinal Obstruction in a Patient with Behçet’s Disease: Report of a Case

A 50-year-old man with Behçets disease and a history of aortobifemoral (ABF) bypass grafting for an abdominal aortic aneurysm was admitted to our Emergency Room with ileus. Upon exploration we found that the ABF graft was occluding the jejunal passage. To the best of our knowledge this is the first such case ever to be reported.     

Gallstone ileus with multiple stones: Where Rigler triad meets Bouveret’s syndrome

A 53-year-old man with multiple medical conditions presented to the emergency department with complaints of vomiting, anorexia and diffuse colicky abdominal pain for 3 d. A computed tomography scan of the abdomen and pelvis showed radiographic findings consistent with Rigler triad seen in small proportion of patients with small bowel obstruction secondary to gallstone impaction. In addition there was a gastric outlet obstruction, consistent with Bouveret’s syndrome. The patient underwent an exploratory laparotomy and enterotomy with multiple stones extracted. The patient had an uneventful post-surgical clinical course and was discharged home.     

Gossypiboma Presenting as Coloduodenal Fistula – Report of a Rare Case With Review of Literature

The term gossypiboma is used to describe a mass of cotton matrix left behind in a body cavity intraoperatively. The most common site reported is the abdominal cavity. It can present with abscess, intestinal obstruction, malabsorption, gastrointestinal hemorrhage, and fistulas. A 37-year-old woman presented with pain in the right hypochondrium for 2 months following open cholecystectomy. As she did not improve with proton pump inhibitors, an esophagogastroduodenoscopy (EGD) was done, which showed a possible gauze piece stained with bile in the first part of the duodenum. Contrast-enhanced computed tomography (CECT) of the abdomen revealed an abnormal fistulous communication of the first part of duodenum with proximal transverse colon, with a hypodense, mottled lesion within the lumen of the proximal transverse colon plugging the fistula, suggestive of a gossypiboma. Excision of the coloduodenal fistula, primary duodenal repair, and feeding jejunostomy was done. The patient recovered well and is now tolerating normal diet. Coloduodenal fistula is usually caused by Crohn''s disease, malignancy, right-sided diverticulitis, and gall stone disease. Isolated coloduodenal fistula due to gossypiboma has not been reported in the literature so far to the best of our knowledge. We report this case of coloduodenal fistula secondary to gossypiboma for its rarity and diagnostic challenge.Key words: Surgical sponges, Intestinal fistula, Multidetector computed tomographyThe first report of a coloduodenal fistula was by Haldane in 1862, and it was malignant from the hepatic flexure.¹ Coloduodenal fistula is caused by Crohn''s disease, malignancy, right-sided diverticulitis, and gall stone disease, but isolated coloduodenal fistula due to gossypiboma has not been reported in the literature to the best of our knowledge. Gossypiboma is known to present as intra-abdominal abscess, intestinal obstruction, and fistulization, but coloduodenal fistula has not been reported as a mode of presentation. We report this case of coloduodenal fistula secondary to gossypiboma for its rarity and diagnostic challenge.     

Posterior Mediastinal Localization of Castleman’s Disease: Report of a Case

Castlemans disease, defined as angiofollicular lymphoid hyperplasia, is a rare lymphoproliferative disorder, which usually occurs in the chest. The tumor is often asymptomatic, but it can cause nonspecific thoracic symptoms such as cough and dyspnea. Surgical removal is curative and malignant transformation has not been described. We report an unusual case of Castlemans disease localized in the posterior mediastinum and bordering the chest wall, and review the relevant literature.