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BOUVERET’S SYNDROME: A CASE OF IMPACTED GALLSTONE
Visceral artery pseudoaneurysms include aneurysms of the celiac, superior, or inferior mesenteric arteries and their branches. Pseudoaneurysms have a high risk of rupture with life threatening consequences.
Case Presentation:
A 63-year-old male with a history of alcohol-related pancreatitis presented with obstructive jaundice. He was afebrile and hemodynamically stable on presentation. Physical exam noted scleral icterus, jaundice, and central excoriations. Labs were significant for hemoglobin 12.1 g/dL, total bilirubin 16.3 mg/dL, AST 152 U/L, ALT 131 U/L, ALP 591 U/L, and lipase 40 U/L. Computed tomography scan was significant for intra- and extra-hepatic ductal dilation, and a 3 cm cystic lesion in the head of pancreas. Endoscopic ultrasound (EUS) revealed a 30 x 30mm round lesion with turbulent swirling flow arising from the gastroduodenal artery and compressing the distal bile duct (Image 1). Doppler revealed an arterial “to-and-fro” waveform, consistent with a gastroduodenal artery pseudoaneurysm (Image 2). Endoscopic retrograde cholangiography revealed severe compression of the distal bile duct, and a covered metal stent was placed. The patient underwent angiography confirming a large gastroduodenal artery pseudoaneurysm, which was treated with vascular coils.
Discussion:
The “to-and-fro” waveform on Doppler is an important diagnostic clue to the presence of a pseudoaneurysm. The “to” represents the arterial blood going into the pseudoaneurysmal sac in systole, while “fro” illustrate blood exiting the sac in diastole. Recognition of this sign on EUS is important as pseudoaneurysms can be missed on cross-sectional imaging.

Image 1. Endoscopic Ultrasound

Image 2. Endoscopic Ultrasound Pulsed Wave Doppler
Biliary cast syndrome (BCS) without liver transplantation is a rare entity. The etiology of BCS is unknown and carries a poor prognosis. Documented risk factors include post-transplant bile duct injury, ischemia, infection, and gallbladder dysmotility. Here we present a rare case of BCS without a liver transplant.
Case:
A 41-year-old male with a past medical history of hypertension and substance use presented with a hypertensive emergency due to medication non-adherence and cocaine use. Our patient had a protracted ICU course complicated with hypoxia-induced cardiac arrest and critical illness myopathy 6-8 months prior.
On the floor, the patient was persistently febrile and complained of diffuse abdominal pain, and the physical exam was positive for left upper quadrant tenderness. Laboratory values demonstrated leukocytosis with neutrophil predominance and evidence of cholestasis with alkaline phosphatase (ALP) 802 U/L, aspartate aminotransferase (AST) 138 U/L, alanine transaminase (ALT) 284 U/L and bilirubin 0.6 mg/dl; however, the infectious workup was negative.
CT chest showed multiple ill-defined right hepatic hypodensities involving more than 50% of parenchyma consistent with hepatic abscess. Magnetic resonance cholangiopancreatography (MRCP) demonstrated innumerable hyperintense and hypointense lesions with peripheral enhancement (Fig. 1), as well as linear hypointense structures in the right hepatic duct (RHD), common hepatic duct (CHD), and common bile duct (CBD). Subsequent endoscopic ultrasound (EUS) showed an isoechoic linear structure and mildly dilated CHD (7mm).
Endoscopic retrograde cholangiopancreatography (ERCP) was performed, and a cholangiogram confirmed a filling defect in CBD, CHD, and RHD. Then Single-user SpyGlass Cholangioscopy confirmed an obstructing linear object in RHD. The balloon sweep removed a long (10-12 cm) bifurcated structure, and the cholangiogram confirmed clearance. The gross specimen was tan-brown, measuring 1 cm x 10.5 cm (Fig. 2), and histopathology demonstrates a bile cast with pigmented debris, purulent inflammation, and ductal epithelium.
The patient was improving post-ERCP, and a CT abdomen and pelvis showed unenhanced liver without biliary duct dilation; however, persistent cholestatic LFTs were noted after two months with ALP of 1410U/L, AST 147 U/L, ALT 281 U/L, and bilirubin 0.7 mg/dl.
Conclusion:
This clinical picture was consistent with critical illness cholangiopathy-induced BCS. Contributing factors include fasting, parenteral feeding, hepatic ischemia, and increased bile viscosity resulting in biliary casts. There is no established standard care for managing BCS; however, ERCP has shown promising results. Moreover, monitoring patients with protracted ICU course and abnormal LFTs may be prudent for recognizing persistent cholangiopathy and BCS-related complications.

MRCP with and without IV contrast demonstrates: (Green arrows) Innumerable T2 hyperintense/T1 hypointense lesions with peripheral enhancement, especially in the right hepatic lobe. (Yellow arrow) Linear T2 hypointense structures in the RHD, CHD, and CBD.

The tan-brown gross specimen measured 1 cm x 10.5 cm in the formalin-embedded cassette.
Case Description:
Case 1: A 67-year-old female with metastatic lung adenocarcinoma who was on pemetrexed and pembrolizumab infusions every 3 weeks for the past year. She developed acute pancreatitis (AP) with acute onset abdominal pain, nausea, vomiting and was found to have a 6-fold elevation of lipase. ICI was discontinued and prednisone 1 mg/kg was started with rapid improvement. She had relapsing AP on steroid taper with a 7-fold lipase elevation and radiographic changes consistent with AP. Evaluation for alternate etiology of AP was unrevealing. She was started on azathioprine (AZA) along with high-dose prednisone. She developed AZA-induced hepatitis and diarrhea during dose titration. She was switched to mycophenolate mofetil (MMF) and titrated up to 2000 mg/day. Prednisone was completely weaned off and has maintained remission of ICI-IP over 10 months.
Case 2: A 53-year-old female with metastatic fibrosarcoma was started on nivolumab and ipilimumab. She developed AP characterized by abdominal pain, radiographic changes, and a 23-fold lipase elevation after 4 cycles. Evaluation for alternate etiology of AP was unrevealing. ICI was discontinued and prednisone 1 mg/kg was started with rapid improvement. However, AP recurred when tapering prednisone below 20 mg/day. MMF was started but discontinued due to pedal edema. She was switched to mycophenolate sodium and titrated to 720 mg BID. This was ineffective as she had recurrence of AP when prednisone was tapered below 20mg/day. AZA was started along with high-dose prednisone and titrated to 2mg/kg/day. AP recurred when prednisone was completely tapered. Patient was able to maintain remission of ICI-IP on a combination of AZA and low-dose prednisone (currently 7.5mg/day) over 5 months.
Discussion: This case series is the first to describe the use of immunomodulators in treatment of steroid-dependent recurrent ICI-IP. Both patients achieved remission of ICI-IP without need for maintenance high-dose steroids. Immunomodulators have their own set of unique adverse events which requires careful monitoring. Further studies are needed to validate its effectiveness and use.



CT angiogram abdomen/pelvis coronal view showing 7 mm distal GDA pseudoaneurysm (blue arrows)
CASE PRESENTATION: In 2019 a 40-years-old female underwent laparoscopic proctocolectomy with ileal pouch-anal anastomosis and adjuvant chemotherapy for long-standing ulcerative colitis complicated by locally advanced transverse colon cancer. In February 2021, an abdominal computed tomography (CT) scan showed confluent 46x16cm mesenteric lymphadenopathies adjacent to the superior mesenteric vein, suggestive of disease recurrence. At multidisciplinary team assessment, patient was considered surgically unresectable because of high risk superior mesenteric vessels injury. Therefore, EUS-guided RFA and SBRT was indicated as LATs options.
In October 2021 patient underwent EUS-RFA with a 19G internally cooled electrode with a 15-mm active tip. RFA needle was inserted into the cranial part of the target lymphadenopathies under EUS guidance and ablation was started. In total, 10 RFA applications at a power setting of 30W were performed for an average time of 10 seconds. After 2 weeks, EUS-RFA was repeated in order to treat the caudal section of the target malignant lymph nodes. 7 RFA applications at a power setting of 30W were performed for an average time of 15 seconds. No early or late complications were observed. In December 2021, the patient underwent 5 consecutive fractions of SBRT for a total dose of 35 Gy. The treatment was well tolerated, with no acute toxicities reported. A 1-month follow-up contrast-enhanced CT scan of the chest and abdomen showed a larger hypodense area within the lymphadenopathies suggestive of complete necrosis, demonstrating a good response to EUS-RFA treatment combined with SBRT.
CONCLUSIONS: Combined treatment with EUS-RFA and SBRT for colorectal lymph node metastases is feasible and safe. These LATs should be considered as likely alternative options in selected patients with oligometastatic disease not eligible for surgery.

Figure 1. On the left (arrow), axial contrast-enhanced CT image shows confluent lymphadenopathies with mixed peripheral enhancement and focal central necrosis in the root of mesentery. On the right (arrow), axial contrast-enhanced CT image shows the same lymphadenopathies completely necrotic one month after the end of treatment.


Case Description: A 75-year-old male with a history of Crohn’s disease and adenocarcinoma of the small bowel status post ileocecectomy 6 years ago presented with vomiting, abdominal pain, and an inability to tolerate oral intake. Due to progression of his cancer, he had developed recurrent, malignant small bowel obstructions which resulted in PEG tube placement for palliative decompression 2 months ago. Initial workup revealed a leukocytosis of 22 with a neutrophilic shift, ESR 36, CRP 46.5, and a lactate of 2.4. A computed tomography scan of the abdomen and pelvis showed extremely severe carcinomatosis with interval development of a small bowel obstruction with a transition point in the right abdomen due to significant tumor burden. A decision was made during Tumor Board to create a palliative fistulous tract between the small bowel and colon. The following week, the patient underwent a lower EUS via a linear echoendoscope. The examined descending colon was normal with the adjacent dilated small bowel identified. A 22mm fine needle aspiration needle was advanced through the descending colonic wall into the adjacent dilated jejunum and subsequent contrast injection confirmed intraluminal position. Via a straight 0.021 inch wire, a 20mm x 10mm LAMS was placed under direct fluoroscopic guidance to create a jejuno-colonic fistula. The patient’s abdominal distention and pain significantly decreased and, after a short course of post-procedural antibiotics, he was discharged home on a liquid diet and palliative measures.
Discussion: To the best of our knowledge, this is the first reported case of a successfully performed EUS-guided LAMS to generate a conduit between the jejunum and descending colon. Adequate colon was preserved distal to the conduit to preserve bowel function and prevent diarrhea. EUS-guided jejunocolostomy via LAMS is a novel but feasible technique for high-level endoscopy centers and provides an effective, nonoperative option for the palliative management of distal, high-grade SBO.

Endoscopic visualization of a successfully placed 20mm x 10mm lumen-apposing metal stent creating a conduit between the jejunum and descending colon.

Post-procedural computed tomography of the abdomen and pelvis without contrast showing diffuse carcinomatosis with tumor burden seen in the right mid-abdomen with multiple enlarged mesenteric lymph nodes and large volume ascites. The jejunocolonic fistula is noted to be in good position in the left lower quadrant.
Abscess cavities communicating with the gastrointestinal tract can be drained via stents. However, stents need to be secured in place. We describe a novel technique to secure stents by using variceal bands.
Materials and methods
We present the case of a patient with an abscess cavity communicating with a J pouch at 3 different leak sites. These leaks had a narrow diameter that allowed passage of contents from the pouch to the cavity but did not allow adequate drainage from the abscess cavity. Drainage was also limited due to the ongoing inflammation in the area.
We advanced a guide wire from the J pouch through one of the leak sites and pulled it out of the other after it traversed the abscess cavity. The same was done for the other leak sites. Over these 2 guide wires, two 7 Fr ureteral stents were advanced into the cavity to allow drainage. We chose these stents as they have multiple openings to facilitate decompression of the abscess cavity.
Stents need to be secured which is often done via suturing or clipping. This however is an expensive approach. Furthermore, sutures and clips tend to cheese wire through the inflamed pouch mucosa and could also lead to occlusion of the stent lumen. Leaving these long stents causes anal irritation and they can end up getting accidentally pulled out after prolapsing. They also cause soiling of undergarments.
To overcome this limitation, we used a novel approach to use variceal bands to secure the stent and then trimmed the stents to prevent prolapse.
Two long free ends of the stent were threaded through the banding kit cap with six bands. The cap was held with a toothed forceps advanced via the therapeutic channel of the scope. Bands were manually fired once the tip of the cap appeared to be in the appropriate position on endoscopic and fluoroscopic view. The stents were trimmed 1 cm distal to the band location with reusable endoscopic scissors.
These bands offer a distinct advantage as they don’t slip due to friction forces and yet don’t occlude the stent lumen thus allowing adequate drainage. The cost is significantly lower than suturing or clipping which invariably fail due to cheese wiring.
Results
The patient is symptom free at a follow up of 3 weeks and the abscess cavity has resolved.
Conclusion
Securing stents via bands to facilitate draining is a novel technique which allows drainage of contents without compromising the lumen of the stents and avoids stent migration from failed clips or sutures

Endoscopic image showing the two ureteral stents held in place with bands.

Fluoroscopic image showing both stents
Bouveret’s syndrome is a rare cause of gastric outlet obstruction due to a lodged gallstone in the duodenal bulb. It was first reported in the 1700s and contributes to 2-3% of gallstone-related gastrointestinal tract obstructions. Stone reaches the small bowel through a bilioenteric fistula that forms due to chronic inflammation. Diagnosis comprises of a combination of clinical presentation, radiological modalities, and endoscopic interventions. We report a case of Bouveret’s syndrome complicated by cholecystitis managed via electrohydrolithotripsy (EHL), endoscopic transgastric drainage, endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ) and Roux-en-Y gastrojejunostomy.
Case Presentation
Patient is a 55-year-old female with a history of insulin-dependent diabetes presented with severe abdominal pain and fevers, associated with nausea and vomiting. Hemodynamics were within normal limits. Laboratory workup was notable for leukocytosis (11 thousand/ul), elevated liver biochemistry profile (alkaline phosphatase 571 IU/L, total bilirubin 5.6 mg/dL and direct bilirubin 3.8 mg/dL). Abdominal ultrasound and computed tomography scan of the abdomen with intravenous contrast (Figure 1) revealed cholecystitis and a large (5x4 cm) gallstone eroding into the gallbladder wall adjacent to the duodenal bulb. Broad-spectrum antibiotics were initiated, and patient underwent an esophagogastroduodenoscopy. This revealed a large, eroded gallstone obstructing the posterior duodenal bulb. (Figure 2) The large stone could not be mobilized. EHL successfully partially fragmented the stone, allowing endoscopic placement of two transgastric double pigtail plastic stents across the resultant cholecystoduodenal fistula, to achieve gallbladder drainage. An EUS-guided gastrojejunostomy with a lumen-apposing metal stent was placed bypassing the gastric outlet obstruction to allow internal drainage of the gallbladder and for feeding. The patient’s clinical status, jaundice, and resultant bacteremia improved. Eventually, the large stone spontaneously dislodged, resulting in distal small bowel obstruction and massive gastrointestinal bleeding, which was not amenable to endoscopic hemostasis. This was treated with a horizontal duodenotomy and stone removal followed by a Roux-en-Y gastrojejunostomy, and retrograde duodenostomy. The patient is currently recovering and in good condition.
Conclusion
Bouveret’s syndrome is often missed in clinical practice due to rarity of presentation and overlapping symptoms with other common etiologies of gastric outlet obstruction. There is no standard algorithm for the management of this rare entity. Our case emphasizes that early diagnosis and immediate surgical intervention is needed if there is high clinical suspicion for this syndrome, however, endoscopic intervention can be a useful temporizing tool to improve overall patient outcome.

Figure 1: CT abdomen with intravenous contrast in an axial plane showing a 50 x 40 mm stone (White Arrow) eroding the gallbladder wall adjacent to the duodenum (blue arrow)

Figure 2:
A) EGD showing a large stone in the posterior bulb with ulceration of the surrounding mucosa
B) EUS showing the same stone (echogenic focus-blue arrow) with poster acoustic shadowing