BOUVERET’S SYNDROME: A CASE OF IMPACTED GALLSTONE

Introduction:
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.

Background:
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.

Introduction: Immune checkpoint inhibitors (ICI), have been integral in the recent advancement of cancer treatment. ICI-induced pancreatitis (ICI-IP) is a rare immune-related adverse event with a reported incidence of 1-2%. High-quality data to guide management is limited. Current treatment paradigm involves a course of steroids and consideration for ICI cessation based on severity. There is a small under recognized subset of patients with relapsing pancreatitis after steroid cessation, often several months after discontinuing ICI. There is no consensus on how to treat these patients and, to our knowledge, there has not been any published data on the use of immunomodulators in managing patients with steroid-dependent recurrent ICI-IP.

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.

Background: Gastroduodenal artery (GDA) aneurysm is a rare vascular condition that is potentially life-threatening. We describe a case of endoscopic ultrasound (EUS)-guided thrombin injection as an effective and safe therapeutic strategy for bleeding GDA pseudoaneurysms. Case: A 70-year-old male was transferred to our intensive care unit (ICU) with hemorrhagic shock secondary to acute upper gastrointestinal (GI) bleeding with melena. His medical history was significant for gastroesophageal reflux disease on Omeprazole. Computed tomography (CT) abdomen showed thickening of the gastric antrum and D1 duodenal segment with no active extravasation. He was started on IV PPI, however his hemoglobin dropped from 12.9 g/dL to 8.6 g/dL (ref range: 12.5-17) with increasing vasopressor requirements. Massive transfusion protocol (MTP) was activated. An urgent EGD was performed however visualization was poor due to blood and clots within the duodenum that could not be adequately suctioned. Rescue therapy with interventional radiology (IR) or surgery was recommended. Given the lack of target for embolization, he underwent surgery and had an exploratory laparotomy, duodenotomy and GDA suture ligation. Intraoperative findings described a perforated D1 duodenal ulcer and bleeding GDA. He stabilized post-operatively but twenty days after surgery, developed recurrent GI bleeding. MTP was again activated. An EGD was arranged, which did not locate a site of active bleeding but visualized stigmata of bleeding and a Forrest IIa ulcer at the duodenal cap; presumably the site of surgical oversewing. This was treated with epinephrine injection and gold probe cautery, but due to persistent GI bleeding, IR embolization was subsequently performed with successful coil embolization of the GDA and supplying branches. Five days later, he was again noted to have acute anemia. Subsequent CT angiogram demonstrated a 7 millimeter distal GDA pseudoaneurysm (Figure 1), which was inaccessible via angiography given prior embolization. He underwent planned EUS-guided thrombin injection of the GDA pseudoaneurysm for occlusion of the pseudoaneurysm. With EUS guidance, the pseudoaneurysm was identified from the duodenum and coil within was visualized. Doppler flow was used, and flow noted within the pseudoaneurysm. Using a 22-gauge fine-needle aspirate needle, 7 cc of 500 IU/cc Tromboject was injected into the pseudoaneurysm and feeding branches. Once the injection was complete, Doppler flow signal was lost in the pseudoaneurysm. There were no post-procedure complications. CT angiogram after 6 weeks revealed the pseudoaneurysm arising from the GDA had remained thrombosed, indicating successful endoscopic occlusion. Hemoglobin remained stable. Conclusion: EUS-guided thrombin injection is a novel approach that is presented as a suitable option in the management of bleeding GDA pseudoaneurysms.

BACKGROUND AND AIM: Oligometastatic colorectal cancer (CRC) is a clinically relevant entity, and surgery is the gold standard therapeutic option. Current guidelines recommend evaluating other local ablative treatments (LATs) in patients not eligible for surgery. Endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) and stereotactic body radiation therapy (SBRT) are emerging as highly beneficial less-invasive LATs in alternative to surgery. We herein report the first case in the literature of lymph node metastases from CRC treated sequentially with EUS-RFA and SBRT.
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.

Background: Cystic artery pseudoaneurysms are usually seen as a complication of cholecystectomy. Infrequently, they can develop in the setting of cholecystitis and present as hemobilia when the aneurysm ruptures. We present the rare case of a cystic artery pseudoaneurysm as a source of hemobilia. Case Report: An 88-year-old male with a history of hypertension and seizure disorder was brought to the emergency department for altered mental status, fevers, and abdominal pain for one day . Labs showed elevated liver enzymes predominantly in a cholestatic pattern with bilirubinemia (alkaline phosphatase 728 U/L, AST 284 U/L, ALT 170 U/L, total bilirubin 3.4 mg/dL, and direct bilirubin on 3.1mg/dL). Labs were also significant for mild leukocytosis and with a hemoglobin drop from 8.5 g/dL to 6.5 g/dL without overt signs of bleeding. CT abdomen showed cholelithiasis, distended gallbladder, and a dilated common bile duct to 11 mm with intrahepatic dilation without evidence of any pancreatic or ampullary mass (Image 1A). During ERCP, blood was seen oozing from the ampulla (Image 1B). Stones and blood clots were swept from the duct and a metal stent was placed. Given persistent melena requiring transfusion post ERCP, CT abdomen with angiogram was performed which showed a large pseudoaneurysm of the cystic artery likely causing intermittent bleeding (Image 2A). Interventional radiology was consulted for embolization. The inflow from the cystic artery was coiled and the angiogram revealed no residual filling of the cystic artery and the pseudoaneurysm (Image 2B). The patient recovered uneventfully post embolization and is planned for a cholecystectomy. Discussion: Hemobilia usually occurs from iatrogenic injury involving liver parenchymal or biliary tract instrumentation. Rarely, hemobilia can occur from cystic artery pseudoaneurysm. It is suggested that the inflammation in cholecystitis leads to arterial wall weakening and subsequent pseudoaneurysm formation. Embolization is an effective treatment modality and risk of gangrenous cholecystitis post embolization is uncommon. Though rare, cystic artery pseudoaneurysms should be considered when hemobilia is seen in the setting of acute cholecystitis.

Introduction: Malignant small bowel obstruction (SBO) is typically managed with operative intervention via an ileostomy or palliative decompression via a nasogastric tube or venting percutaneous endoscopic gastrostomy (PEG). Placement of a lumen-apposing metal stent (LAMS) for duodenal obstructions is well-established since the late 2010s but distal SBOs are more technically challenging to manage endoscopically. Here, we present an innovative case of an endoscopic ultrasound (EUS)-guided jejunocolostomy for the palliation of severe carcinomatosis and malignant distal SBO.

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.

Background and aims

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

Background
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.