Gastric Outlet Obstruction in a Patient with Bouveret's Syndrome: a Case Report

BACKGROUND: Gallstone ileus accounts for 1% to 4% of cases of mechanical bowel obstruction, but may be responsible for up to 25% of cases in older age groups. In non-iatrogenic cases, gallstone migration occurs after formation of a biliary-enteric fistula. In fewer than 10% of patients with gallstone ileus, the impacted gallstones are located in the pylorus or duodenum, resulting in gastric outlet obstruction, known as Bouveret's syndrome. CASE PRESENTATION: We report an 86-year-old female who was admitted to hospital with a 10-day history of persistent vomiting and prostration. She was in hypovolemic shock at the time of arrival in the emergency department. Investigations revealed a gallstone in the duodenal bulb and a cholecystoduodenal fistula. She underwent surgical gastrolithotomy. Unfortunately, she died of aspiration pneumonia on the fourth postoperative day. CONCLUSION: This case shows the importance of considering Bouveret's syndrome in the differential diagnosis of gastric outlet obstruction, especially in the elderly, even in patients with no previous history of gallbladder disease.

Neurogenic Thoracic Outlet Syndrome Associated with Cervical Rib

A true neurogenic thoracic outlet syndrome (TOS) associated with a cervical rib is considered extremely rare. The authors present their experience with 5 cases of true neurogenic TOS associated with a cervical rib. All patients were female and had a cervical rib confirmed radiographically pre-operatively. Average age was 34,8 years. Although all patients had been treated with several combinations of diverse drugs and a rehabilitation program before referral to surgery, all described their pain as intense and debilitating before surgical treatment. All patients had pre-operative electromyographic abnormalities. Patients were operated on via a supraclavicular approach and the cervical rib was resected. No intra-operative or postoperative complications were noted. Two years postoperatively, all patients mentioned improvement. However, only 2 were symptomless, and on no medication. In one patient there was significant improvement, and in the remaining 2 patients some residual pain persisted that had to be dealt with pharmacologically. All patients were able to resume their daily life activities. Recovery was poorer in the 2 patients that had been referred to surgery after a longer period of time since the beginning of symptoms.