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1.  Development of a duodenal gallstone ileus with gastric outlet obstruction (Bouveret syndrome) four months after successful treatment of symptomatic gallstone disease with cholecystitis and cholangitis: a case report 
Introduction
Cases of gallstone ileus account for 1% to 4% of all instances of mechanical bowel obstruction. The majority of obstructing gallstones are located in the terminal ileum. Less than 10% of impacted gallstones are located in the duodenum. A gastric outlet obstruction secondary to a gallstone ileus is known as Bouveret syndrome. Gallstones usually enter the bowel through a biliary enteral fistula. Little is known about the formation of such fistulae in the course of gallstone disease.
Case presentation
We report the case of a 72-year-old Caucasian woman born in Germany with a gastric outlet obstruction due to a gallstone ileus (Bouveret syndrome), with a large gallstone impacted in the third part of the duodenum. Diagnostic investigations of our patient included plain abdominal films, gastroscopy and abdominal computed tomography, which showed a biliary enteric fistula between the gallbladder and the duodenal bulb. Our patient was successfully treated by laparotomy, duodenotomy, extraction of the stone, cholecystectomy, and resection of the fistula in a one-stage surgical approach. Histopathological examination showed chronic and acute cholecystitis, with perforated ulceration of the duodenal wall and acute purulent inflammation of the surrounding fatty tissue. Four months prior to developing a gallstone ileus our patient had been hospitalized for cholecystitis, a large gallstone in the gallbladder, cholangitis and a small obstructing gallstone in the common biliary duct. She had been treated with endoscopic retrograde cholangiopancreatography, endoscopic biliary sphincterotomy, balloon extraction of the common biliary duct gallstone, and intravenous antibiotics. At the time of her first presentation, abdominal ultrasound and endoscopic examination (including esophagogastroduodenoscopy and endoscopic retrograde cholangiopancreatography) had not shown any evidence of a biliary enteral fistula. In the four months preceding the gallstone ileus our patient had been asymptomatic.
Conclusion
In patients known to have gallstone disease presenting with symptoms of ileus, the differential diagnosis of a gallstone ileus should be considered even in the absence of preceding symptoms related to the gallbladder disease. Gallstones large enough to cause intestinal obstruction usually enter the bowel by a biliary enteral fistula. During the formation of such a fistula, patients can be asymptomatic.
doi:10.1186/1752-1947-4-376
PMCID: PMC2997099  PMID: 21092262
2.  Reconstruction of a traumatic duodenal transection with a pedicled ileal loop: a case report 
Introduction
Blunt duodenal injuries do not occur often. A patient with damage to the duodenal tissue around the pancreatic and common bile duct presents a challenge to surgeons. The choice of procedure must be tailored to the nature of the defect and the amount of tissue lost.
Case presentation
We describe the case of a 16-year-old Caucasian boy with a blunt duodenal injury after a motor vehicle accident. On admission, the patient had stable vital signs and a normal laboratory workup. Gradually his clinical condition deteriorated and a computed tomography scan showed a retroperitoneal haematoma at the level of his duodenum. A fully circumferential rupture of the second part of his duodenum was found during laparotomy, with the intact Vater's papilla lying adjacent to the defect and a superficial laceration of the head of his pancreas. The retroperitoneal haematoma was thoroughly drained and a pedicled ileal loop was interposed between the duodenal stumps to restore the continuity of the patient's duodenum. Apart from a mild postoperative pancreatitis, the patient's postoperative course evolved with no further problems. The patient was discharged on the 22nd postoperative day in excellent condition and has remained so to date (after five years).
Conclusion
In our case report, where the second part of the patient's duodenum was completely transected, our choices for reconstruction were limited. Important factors for the successful management of this patient were prompt surgical intervention and the accurate assessment of the nature of the duodenal and associated injuries. We believe that the technique we used was a reasonable choice because the anatomical continuity of the patient's duodenum was restored.
doi:10.1186/1752-1947-4-343
PMCID: PMC2987957  PMID: 20977717
3.  Laparoscopic treatment of an upper gastrointestinal obstruction due to Bouveret’s syndrome 
Bouveret’s syndrome is an extremely rare type of gallstone-induced ileus with atypical clinical manifestations, such as abdominal distension and pain, nausea and vomiting, fever or even gastrointestinal bleeding, which may easily be misdiagnosed. In the present case, a 55-year-old male was admitted to the hospital with upper gastrointestinal obstructive symptoms but without pain, fever, jaundice or melena. At first, gastrolithiasis and peptic ulcer combined with pyloric obstruction were suspected after gastroscopy revealed a large, hard stone in the duodenal bulb. A revised diagnosis of Bouveret’s syndrome was made following abdominal computed tomography. Subsequently, the patient exhibited a good postoperative recovery after laparoscopic duodenotomy for gallstone removal and subtotal cholecystectomy. The condition of the patient remained stable after being followed up for 6 mo. The successful application of laparoscopic therapy to treat Bouveret’s syndrome has seldom been reported. Laparoscopic enterolithotomy is safe and effective, with good patient tolerability, rapid postoperative recovery and few wound-related complications. The laparoscopic treatment of Bouveret’s syndrome is worth exploring.
doi:10.3748/wjg.v19.i40.6943
PMCID: PMC3812499  PMID: 24187475
Bouveret’s syndrome; Gallstone; Gastric outlet obstruction; Laparoscopic therapy; Cholecystoenteric fistula
4.  Bouveret's syndrome: revisiting gallstone obstruction of the duodenum. 
Bouveret's Syndrome is obstruction of the duodenum secondary to an impacted gallstone, usually without the presence of pneumobilia. With the steadily increasing life expectancy, greater numbers of these cases are being seen. Gallstones enter the gastrointestinal tract following fistula formation between the gallbladder and an adjacent hollow viscus and may cause obstruction at any point along the intestinal tract. Duodenal obstruction is the least common and represents only a very small percentage of cases. The presenting signs of nausea vomiting, abdominal cramping, and the absence of abdominal distension should alert the clinician to pathology in the proximal small bowel. The purpose of this report is to heighten the awareness of the primary care physicians, emergency room doctors, and surgeons to this diagnosis in elderly patients so that it can be included in the differential with the usual causes of gastric outlet obstruction--including ulcer disease; neoplasm; gastric volvulus; and other enteroliths, such as bezoars. Early diagnosis is critical, as these cases require urgent surgical intervention. Early resuscitation, diagnosis, and treatment are essential for a successful outcome.
Images
PMCID: PMC2594488  PMID: 14620710
5.  Gastric outlet obstruction in a patient with Bouveret’s syndrome: a case report 
BMC Research Notes  2013;6:195.
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.
doi:10.1186/1756-0500-6-195
PMCID: PMC3660164  PMID: 23663702
Bouveret’s syndrome; Gallstone ileus; Gastric outlet obstruction; Cholecystoduodenal fistula
6.  Bouveret's syndrome complicated by distal gallstone ileus after laser lithotropsy using Holmium: YAG laser 
BMC Gastroenterology  2002;2:15.
Background
Bouveret's syndrome is an unusual presentation of duodenal obstruction caused by the passage of a large gallstone through a cholecystoduodenal fistula. Endoscopic therapy has been used as first-line treatment, especially in patients with high surgical risk.
Case presentation
We report a 67-year-old woman who underwent an endoscopic attempt to fragment and retrieve a duodenal stone using a Holmium: Yttrium-Aluminum-Garnet Laser (Ho:YAG) which resulted in small bowel obstruction. The patient successfully underwent enterolithotomy without cholecystectomy or closure of the fistula.
Conclusion
We conclude that, distal gallstone obstruction, due to migration of partially fragmented stones, can occur as a possible complication of laser lithotripsy treatment of Bouveret's syndrome and might require urgent enterolithotomy.
doi:10.1186/1471-230X-2-15
PMCID: PMC117132  PMID: 12086587
7.  Novel technique for biliary reconstruction using an isolated gastric tube with a vascularized pedicle: a live animal experimental study and the first clinical case 
Background
Biliary tract reconstruction continues to be a challenging surgical problem. Multiple experimental attempts have been reported to reconstruct biliary defects with different materials and variable outcome. Our aim was to evaluate a new method for biliary reconstruction using an isolated pedicled gastric tube in a live animal trial and also to present the first clinical case.
Methods
Seven mongrel dogs underwent biliary reconstruction using gastric tube harvested, completely separated from the greater curvature, and based on a vascularized pedicle with the right gastroepiploic vessels. The tube was interposed between the common bile duct (CBD) and the duodenum. Postoperative mortality, morbidity, liver functions, gross and microscopic histological picture were assessed. The first clinical case was also presented where, in a patient with post-cholecystectomy biliary injury, an isolated pedicled gastric tube was interposed between the proximal and distal ends of the CBD.
Results
One dog did not recover from anesthesia and another one died postoperatively from septic peritonitis. Five dogs survived the procedure and showed uneventful course and no cholestasis. The mean anastomotic circumference was 4.8 mm (range 4-6) for CBD anastomosis and 6.2 mm (range 5-7) for duodenal anastomosis. Histologically, anastomotic sites showed good evidence of healing. In the first clinical case, the patient showed clinical and biochemical improvement. Endoscopic retrograde cholangiography was feasible and assured patent biliary anastomoses.
Conclusion
In mongrel dogs, biliary reconstruction using pedicled gastric tube interposition between CBD and duodenum is feasible with satisfactory clinical results, anastomotic circumference and histological evidence of healing. The technique is also feasible in human and seems to be promising.
doi:10.1186/1750-1164-5-8
PMCID: PMC3198750  PMID: 21985492
8.  Bouveret’s syndrome: should we remove the gall bladder? 
BMJ Case Reports  2011;2011:bcr0220113891.
Bouveret’s syndrome is a rare cause of intestinal obstruction caused by gallstones and is usually seen in older patients with poor medical status. The surgical treatment for these patients is controversial. The authors present a case of a 73-year-old woman who presented with coffee ground vomiting. An upper gastrointestinal endoscopy showed a big gallstone obstructing the duodenal bulb and a CT scan showed a cholecystoduodenal fistula. The stone could not be removed or crushed endoscopically and a laparotomy was undertaken to relieve the obstruction. The stone was removed by gastrotomy and a delayed cholecystectomy was not offered due to her co-morbid conditions. She presented 18 months later with pancreatitis and has now been offered an elective cholecystectomy.
doi:10.1136/bcr.02.2011.3891
PMCID: PMC3079472  PMID: 22700609
9.  Resolving sphincter of Oddi incontinence for primary duodenal Crohn's disease with strictureplasty 
INTRODUCTION
Crohn's involvement of duodenum is a rare event and may be associated to proteiform symptoms and uncommon pathological aspects which make diagnosis and treatment complex.
PRESENTATION OF CASE
The peculiar aspect of this case was a suspected duodeno-biliary fistula. The patient (female, 22 years old) was affected by duodenal Crohn's disease. Magnetic resonance imaging showed a dilated common bile duct, whose final part linked to a formation containing fluid, and characterized by filling of the contrast medium in the excretory phase. Abdominal ultrasound showed intra-hepatic and intra-gallbladder aerobilia. At surgery, the duodenum was mobilized showing an inflammatory stricture and a slight dilatation of the common bile duct, with no signs of fistulas. The opened duodenum was anastomized side to side to a transmesocolic loop of the jejunum. After surgery, the general condition of the patient improved.
DISCUSSION
Only two cases of fistula between a narrow duodenal bulb and the common bile duct have been described in literature and the Authors were not be able to verify the occurrence of a duodenal biliary fistula at surgery. The association between duodenal Crohn's disease and Sphincter of Oddi incontinence is a very rare finding with different etiology: chronic intestinal pseudo-obstruction, common bile duct stones, progressive systemic sclerosis.
CONCLUSION
The treatment to resolve Sphincter of Oddi incontinence for primary duodenal Crohn's disease is not clear. Strictureplasty could be the treatment of choice, because, resolving the stricture, the duodenal pressure is likely to decrease and the reflux through the incontinent sphincter can be avoided.
doi:10.1016/j.ijscr.2012.11.016
PMCID: PMC3540232  PMID: 23276753
Duodenal Crohn's disease; Sphincter of Oddi incontinence; Strictureplasty; CD, Crohn's disease; ESR, erythrocyte sedimentation rate; CRP, C-reactive protein; UGI, upper gastro intestinal; MRI, magnetic resonance imaging; CKK, cholecystokinin; SO, Sphincter of Oddi
10.  Carcinoma Gall Bladder with Bouveret’s Syndrome: A Rare Cause of Gastric Outlet Obstruction 
The Indian Journal of Surgery  2010;72(4):350-351.
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.
doi:10.1007/s12262-010-0145-x
PMCID: PMC3002772  PMID: 21938203
Bouveret’s Syndrome; Carcinoma gall bladder; Gastric outlet obstruction
11.  A possible variant of Bouveret's syndrome presenting as a duodenal stump obstruction by a gallstone after Roux-en-Y gastrectomy: a case report 
Introduction
Bouveret's syndrome is characterized by gastric outlet obstruction due to a gallstone in the duodenum, usually in association with a cholecystoduodenal fistula.
Case presentation
We report the case of a 69-year-old Caucasian man who developed duodenal stump obstruction due to an impacted gallstone after having previously undergone Roux-en-Y gastrectomy.
Conclusions
Duodenal stump obstruction after Roux-en-Y gastrectomy is rare, and may be difficult to manage. Patients who present with upper gastrointestinal or pancreatobiliary pathology after previous gastric surgery should be managed in centres with the availability of appropriate endoscopic and surgical experience.
doi:10.1186/1752-1947-3-7301
PMCID: PMC2726511  PMID: 19830173
12.  Gallstone Ileus, Bouveret's Syndrome and Choledocholithiasis in a Patient with Billroth II Gastrectomy – A Case Report of Combined Endoscopic and Surgical Therapy 
Intestinal obstruction due to gallstone is a rare, but quite severe gastrointestinal disorder, which always requires a rapid and correct diagnosis to achieve optimal therapy. Digestive endoscopy is an important method to determine the level of the bowel obstruction and to plan an optimal therapeutic strategy. Our present case demonstrates that in a high-risk patient, a combined endoscopic and surgical therapy is the best choice to solve the obstruction of the colon, of the stomach and of the common bile duct caused by multiple gallstones.
doi:10.1159/000208993
PMCID: PMC2988901  PMID: 21103231
Gallstone disease; Gallstone ileus; Bouveret's syndrome; ERCP; Billroth II gastrectomy; Mechanical lithotripsy
13.  Bouveret's syndrome as an unusual cause of gastric outlet obstruction: a case report 
An 83 year old caucasian gentleman presented with vomiting and left sided abdominal pain. A subsequent upper GI endoscopy demonstrated a large smooth mass impacted within the duodenum. A cholecysto-duodenal fistula was discovered at laparotomy, with a large gallstone impacted in the duodenum. A diagnosis of Bouveret's syndrome was made. The management of this rare cause of gastric outlet obstruction is discussed.
doi:10.1186/1752-1947-1-73
PMCID: PMC2034582  PMID: 17760995
14.  Bouveret's Syndrome: 64-Slice CT Diagnosis and Surgical Management—A Case Report 
Case Reports in Radiology  2012;2012:701216.
Gastric outlet obstruction caused by duodenal impaction of a large gallstone migrated through a cholecystoduodenal fistula has been referred to as Bouveret's syndrome. We present a case of gallstone-induced duodenal obstruction in an elderly female patient, diagnosed on a 64-slice MDCT scanner. One-stage surgery, that is, stone removal and cholecystectomy, was performed resulting in relief of obstruction and complete cure. Clinical features, multidetector computed tomography (MDCT) findings, and surgical management are discussed.
doi:10.1155/2012/701216
PMCID: PMC3512245  PMID: 23346445
15.  Mirizzi syndrome type Va: A rare coexistence of double cholecysto-biliary and cholecysto-enteric fistulae 
World Journal of Radiology  2010;2(10):410-413.
Mirizzi syndrome is a rare cause of intermittent obstructive jaundice, where an impacted stone in the cystic duct or Hartmann’s pouch mechanically obstructs the common bile duct (CBD). We report a rare case of double cholecysto-biliary and cholecysto-enteric fistulae, in a 75-year-old female patient, presenting with a right upper quadrant abdominal pain and intermittent obstructive jaundice. Endoscopic retrograde cholangiopancreatography suggested Mirizzi syndrome. Operative findings included erosions of the lateral wall of the CBD and the second portion of the duodenum due to impacted gallstones. The defects were reconstructed primarily and a Kehr tube was inserted. The patient had an uneventful postoperative course and was discharged on the 14th postoperative day.
doi:10.4329/wjr.v2.i10.410
PMCID: PMC2999013  PMID: 21161027
Mirizzi syndrome; Obstructive jaundice; Gallstone; Cholecysto-enteric fistula; Endoscopic retrograde cholangiopancreatography
16.  Successful Multimodality Endoscopic Treatment of Gastric Outlet Obstruction Caused by an Impacted Gallstone (Bouveret's Syndrome) 
Bouveret's syndrome is a rare condition of gastric outlet obstruction resulting from the migration of a gallstone through a choledochoduodenal fistula. Due to the large size of these stones and the difficult location in which they become impacted, endoscopic treatment is unsuccessful and most patients require surgery. We report the case of an elderly male who presented with nausea and hematemesis, and was found on CT scan and endoscopy to have an obstructing gallstone in his duodenal bulb. After several endoscopic sessions and the use of multiple instruments including a Holmium: YAG laser and electrohydraulic lithotripter, fragmentation and endoscopic removal of the stone were successful. We believe this to be the first case of Bouveret's syndrome successfully treated by endoscopy alone in the United States. We describe the difficulties encountered which necessitated varied and innovative therapeutic techniques.
doi:10.1155/2008/471512
PMCID: PMC2239211  PMID: 18493330
17.  Active bleeding from a periampullary duodenal diverticulum that was difficult to diagnose but successfully treated using hemostatic forceps: a case report 
Introduction
Although duodenal diverticula are common, periampullary duodenal diverticula are rare. Periampullary duodenal diverticula are usually asymptomatic and may be difficult to diagnose and treat. However, they may present with massive bleeding, requiring prompt diagnosis.
Case presentation
We report the case of a 71-year-old Asian woman with bleeding from a periampullary duodenal diverticulum. She presented with severe anemia and tarry stools. Two examinations using a forward-viewing endoscope did not identify the source of the bleeding. However, examination using a side-viewing endoscope found an exposed bleeding vessel overlying the bile duct within a periampullary diverticulum of the descending part of the duodenum. The bleeding was successfully controlled by using hemostatic forceps.
Conclusions
Bleeding periampullary duodenal diverticula are rare, and a bleeding point in the mucosa overlying the bile duct within a large periampullary duodenal diverticulum is very rare. Identification of a bleeding point within a duodenal diverticulum often requires repeated examination and may require the use of a side-viewing endoscope. Use of hemostatic forceps to control bleeding from a periampullary duodenal diverticulum is very rare but, for bleeding lesions overlying the bile duct within a periampullary duodenal diverticulum, is the best way to prevent obstructive jaundice.
doi:10.1186/1752-1947-6-367
PMCID: PMC3485119  PMID: 23101939
Bleeding periampullary duodenal diverticulum; Side-viewing endoscopy; Hemostatic forceps; Obscure gastrointestinal bleeding
18.  INTESTINAL OBSTRUCTION  
Closed duodenal loops may be made in dogs by ligatures placed just below the pancreatic duct and just beyond the duodenojejunal junction, together with a posterior gastro-enterostomy. These closed duodenal loop dogs die with symptoms like those of patients suffering from volvulus or high intestinal obstruction. This duodenal loop may simulate closely a volvulus in which there has been no vascular disturbance. Dogs with closed duodenal loops which have been washed out carefully survive a little longer on the average than animals with unwashed loops. The duration of life in the first instance is one to three days, with an average of about forty-eight hours. The dogs usually lose considerable fluid by vomiting and diarrhea. A weak pulse, low blood pressure and temperature are usually conspicuous in the last stages. Autopsy shows more or less splanchnic congestion which may be most marked in the mucosa of the upper small intestine. The peritoneum is usually clear and the closed loop may be distended with thin fluid, or collapsed, and contain only a small amount of pasty brown material. The mucosa of the loop may show ulceration and even perforation, but in the majority of cases it is intact and exhibits only a moderate congestion. Simple intestinal obstruction added to a closed duodenal loop does not modify the result in any manner, but it may hasten the fatal outcome. The liver plays no essential role as a protective agent against this poison, for a dog with an Eck fistula may live three days with a closed loop. A normal dog reacts to intraportal injection and to intravenous injection of the toxic substance in an identical manner. Drainage of this loop under certain conditions may not interfere with the general health over a period of weeks or months. Excision of the part of the duodenum included in this loop causes no disturbance. The material from the closed duodenal loops contains no bile, pancreatic juice, gastric juice, or split products from the food. It can be formed in no other way than by the activity of the intestinal mucosa and the growth of the intestinal bacteria. This material after dilution, autolysis, sterilization, and filtration produces a characteristic effect when introduced intravenously. When in toxic doses it causes a profound drop in blood pressure, general collapse, drop in temperature, salivation, vomiting, and profuse diarrhea, which is often blood-stained. Splanchnic congestion is the conspicuous feature at autopsy and shows especially in the villi of the duodenal and jejunal mucosæ. Adrenalin, during this period of low blood pressure and splanchnic congestion, will cause the usual reaction when given intravenously, but applied locally or given intravenously it causes no bleaching of the engorged intestinal mucosa. Secretin is not found in the duodenal loop fluid, and the loop material does not influence the pancreatic secretion. Intraportal injection of the toxic material gives a reaction similar to intravenous injection. Intraperitoneal and subcutaneous injections produce a relatively slow reaction which closely resembles the picture seen in the closed duodenal loop dog. In both cases there is a relatively slow absorption, but the splanchnic congestion and other findings, though less intense, are present in both groups. There seems, therefore, to be no escape from the conclusion that a poisonous substance is formed in this closed duodenal loop which is absorbed from it and causes intoxication and death. Injection of this toxic substance into a normal dog gives intoxication and a reaction more intense but similar to that developing in a closed-loop dog.
PMCID: PMC2125034  PMID: 19867644
19.  Complicated Cholelithiasis: An Unusual Combination of Acute Pancreatitis and Bouveret Syndrome 
Case Reports in Gastroenterology  2012;6(2):459-464.
Bouveret syndrome is a rare form of gallstone ileus. The purpose of the present study was to present the unusual case of a female patient with complicated cholelithiasis manifested as a combination of acute pancreatitis and concomitant Bouveret syndrome. A 61-year-old female patient was admitted to the emergency department complaining of mid-epigastric and right upper quadrant abdominal pain radiating band-like in the thoracic region of the back as well as repeated episodes of vomiting over the last 24 h. The initial correct diagnosis of pancreatitis was subsequently combined with the diagnosis of Bouveret syndrome as a computed tomography scan revealed the presence of a gallstone within the duodenum causing luminal obstruction. After failure of endoscopic gallstone removal, a surgical approach was undertaken where gallstone removal was followed by cholecystectomy and restoration of the anatomy by eliminating the fistula. The concomitant pancreatitis complicated the postoperative period and prolonged the length of hospital stay. However, the patient was discharge on the 45th postoperative day. Attempts for endoscopic removal of the impacted stone should be the initial therapeutic step. Surgery should be reserved for cases refractory to endoscopic intervention and when definite treatment is the actual challenge.
doi:10.1159/000341512
PMCID: PMC3398075  PMID: 22855661
Complicated cholelithiasis; Acute pancreatitis; Bouveret syndrome; Duodenal obstruction; Gallstone ileus
20.  The composition of hepatic and gallbladder bile in patients with gallstones 
Gut  1972;13(10):759-762.
Bile specimens were obtained from 17 patients with gallstones and 21 patients with duodenal ulcer. The specimens were obtained from the former by needle aspiration of the gallbladder and common bile duct at operation and from the latter by duodenal intubation. The concentrations of bile salt, phospholipid, and cholesterol were measured. Gallbladder bile from gallstone patients contained significantly more cholesterol than did `duodenal' bile from duodenal ulcer patients. Hepatic bile from gallstone patients contained significantly more cholesterol than did gallbladder bile from the same patients. When the data were plotted on triangular coordinates the relative composition lay within the zone of cholesterol solubility in all 21 ulcer patients. The relative composition of hepatic bile lay outside the zone of cholesterol solubility in five gallstone patients, at the limits of cholesterol solubility in a further three, and within the micellar zone in the remaining nine patients. This suggests that supersaturation of hepatic bile with cholesterol is not the sine qua non for the production of cholesterol gallstones.
PMCID: PMC1412476  PMID: 5087065
21.  Acute cholecystitis with massive upper gastrointestinal bleed: A case report and review of the literature 
BMC Gastroenterology  2007;7:12.
Background
Cystic artery pseudoaneurysm is a rare complication following cholecystitis. Its presentation with upper gastrointestinal hemorrhage (UGIH) is even rarer. Thirteen patients with cystic artery pseudoaneurysm have been reported in the literature but only 2 of them presented with UGIH alone.
Case presentation
We report a 43-year-old woman who developed a cystic artery pseudoaneurysm following an episode of acute cholecystitis. She presented with haematemesis and melaena associated with postural symptoms. Upper gastrointestinal endoscopy revealed a duodenal ulcer with adherent clots in the first part of the duodenum. Ultrasonography detected gallstones and a pseudoaneurysm at the porta hepatis. Selective hepatic angiography showed two small pseudoaneurysms in relation to the cystic artery, which were selectively embolized. However, the patient developed abdominal signs suggestive of gangrene of the gall bladder and underwent an emergency laparotomy. Cholecystectomy with common bile duct exploration along with repair of the duodenal rent, and pyloric exclusion and gastrojejunostomy was done.
Conclusion
This case illustrates the occurrence of a rare complication (pseudoaneurysm) following cholecystitis with an unusual presentation (UGIH). Cholecystectomy, ligation of the pseudoaneurysm and repair of the intestinal communication is an effective modality of treatment.
doi:10.1186/1471-230X-7-12
PMCID: PMC1851966  PMID: 17386110
22.  Anomalous opening of the common bile duct into the duodenal bulb: endoscopic treatment 
BMC Gastroenterology  2007;7:26.
Background
Anomalous biliary opening especially the presence of the ampulla of Vater in the duodenal bulb is a very rare phenomenon. We report clinical implications, laboratory and ERCP findings and also therapeutic approaches in 53 cases.
Methods
The data were collected from the records of 12.158 ERCP. The diagnosis was established as an anomalous opening of the common bile duct (CBD) into the duodenal bulb when there is an orifice observed in the bulb with the absence of a papillary structure at its normal localization and when the CBD is visualized by cholangiography through this orifice without evidence of any other opening.
Results
A total of 53 cases were recruited. There was an obvious male preponderance (M/F: 49/4). Demographic data and ERCP findings were available for all, but clinical characteristics and laboratory findings could be obtained from 39 patients with full records. Thirty – seven of 39 cases had abdominal pain (95%) and 23 of them (59%) had cholangitis as well. Elevated AP and GGT were found in 97.4% (52/53). History of cholecystectomy was present in 64% of the cases, recurrent cholangitis in 26% and duodenal ulcer in 45%. Normal papilla was not observed in any of the patients and a cleft-like opening was evident instead. The CBD was hook shaped at the distal part that opens to the duodenal bulb. Pancreatic duct (PD) was opening separately into the bulb in all the cases when it was possible to visualize. Dilated CBD in ERCP was evident in 94% and the CBD stone was demonstrated in 51%. PD was dilated in four of 12 (33%) cases. None of them has a history of pancreatitis. Endoscopically, Papillary Balloon Dilatation instead of Sphincterotomy carried out in 19 of 27 patients (70%) with choledocholithiazis. Remaining eight patients had undergone surgery (30%). Clinical symptoms were resolved with medical treatment in 16(32%) patients with dilated CBD but no stone. Perforation and bleeding were occurred only in two patients, which stones extracted with sphincterotomy (each complication in 1 patient).
Conclusion
The opening of the CBD into the duodenal bulb is a rare event that may be associated with biliary and gastric/duodenal diseases. To date, surgical treatment has been preferred. In our experience, sphincterotomy has a high risk since it may lead to bleeding and perforation by virtue of the fact that a true papillary structure is absent. However, we performed balloon dilatation of the orifice successfully without any serious complication and suggest this as a safe therapeutic modality.
doi:10.1186/1471-230X-7-26
PMCID: PMC1933541  PMID: 17610747
23.  Ectopic papilla of Vater in the pylorus 
The major papilla of Vater is usually located in the second portion of the duodenum, to the posterior medial wall. Sometimes the mouth of the biliary duct is located in other areas. Drainage of the common bile duct into the pylorus is extremely rare. A 73-year old man, with a history of duodenal ulcer, was admitted to hospital with the diagnosis of cholangitis. Dilatation of the extrahepatic biliary duct was observed by abdominal ultrasonography, and endoscopic retrograde cholangiopancreatography (ERCP) was performed. No area suggesting the presence of the papilla of Vater was found within the second duodenal portion. Finally the major papilla was located in the theoretical pyloric duct. Cholangiography was performed and choledocholithiasis was found in the biliary tree. The patient underwent dilatation of the papilla with a balloon tyre and removal of a 7 mm stone using a Dormia basket, which solved the problem without further complications. This anomaly increased the difficulty of performing therapeutic interventions during ERCP. This alteration in anatomy may increase the risk of complications during papillotomy, with a theoretically higher risk of perforation. Dilatation using a balloon was the chosen therapeutic technique both in our case and in the literature, due to its low rate of complications.
doi:10.3748/wjg.15.5221
PMCID: PMC2773904  PMID: 19891024
Ectopic common bile duct; Endoscopic dilatation; Endoscopic retrograde cholangiopancreatography; Papilla of Vater; Papillotomy; Pyloric drainage
24.  Regulation of the fasting enterohepatic circulation of bile acids by the migrating myoelectric complex in dogs. 
Journal of Clinical Investigation  1983;71(3):644-654.
The purpose of this study was to correlate the fasting enterohepatic circulation (EHC) of bile acids with the migrating myoelectric complex. Four dogs were surgically provided with a functional cholecystectomy, a duodenal cannula for direct vision cannulation of the common bile duct, and 12 bipolar electrodes implanted from stomach to terminal ileum. Bile was collected in equal-volume, timed aliquots over 6 to 10 h. Aliquots were sampled and either returned to the duodenum for study of the intact EHC, or collected and retained in order to study the time course of the bile acid pool washout. In the washout experiments boluses of radiolabeled taurocholic acid were instilled into the duodenum before and after duodenal phase III of the migrating motor or myoelectric complex (MMC). In another group of experiments the bile acid pool was washed out and during a continuous duodenal infusion of taurocholic acid bile was collected to study the pattern of hepatic secretion. Results: (a) In all experiments, a single broad peak of bile flow and bile acid secretion occurred at 35-55% of the MMC migration time. At this time the MMC had migrated to a point 70-85% of the distance along the small intestine. (b) During bile acid pool washout the peak of bile flow and bile acid secretion occurred with the distal migration of the first MMC and then bile flow and bile acid secretion rates decreased to a minimum and stabilized. (c) In bile acid pool washout experiments the radiolabeled bile acids instilled into the duodenum prior to duodenal phase III were secreted and peaked with peak endogenous bile acid secretion. The secretion of radiolabeled bile acids instilled into the duodenum after duodenal phase III was delayed until the subsequent cycle of the MMC. 88% of the bile acid pool collected over 6 h was secreted during the distal migration of the first MMC (2.4 +/- 0.4 h). (d) After bile acid pool washout and during continuous duodenal infusion of taurocholic acid, hepatic bile flow and bile acid secretion continued to fluctuate with the same pattern observed with the EHC intact. Conclusions: (a) In the fasting state, the transport of intestinal bile acids to the liver is pulsatile rather than continuous and is determined by the MMC. Maximum hepatic secretion occurs when phase III of the MMC propels the intraluminal bile acid pool to its site of absorption in the distal small bowel. (b) The "housekeeping" action of the MMC is very efficient and clears 88% of the 6-h washout bile acid pool in one pass.
PMCID: PMC436914  PMID: 6826728
25.  Bouveret Syndrome—The Rarest Variant of Gallstone Ileus: A Case Report and Literature Review 
Case Reports in Surgery  2013;2013:839370.
We present a case report of a patient with Bouveret syndrome with interesting radiological findings and successful surgical treatment after failure of the endoscopic techniques. The report is followed by a review of the literature regarding the diagnostic means and proper treatment of this rare entity. Bouveret syndrome refers to the condition of gastric outlet obstruction caused by the impaction of a large gallstone into the duodenum after passage through a cholecystoduodenal fistula. Many endoscopic and surgical techniques have been described in the management of this syndrome. This is a case of a 78-year-old patient with severe medical history who presented in bad general condition with an 8-day history of nausea, multiple bilious vomiting episodes, anorexia, discomfort in the right hypochondrium and epigastrium, and fever up to 38,5°C. The diagnosis of Bouveret syndrome was set after performing the proper imaging studies. An initial endoscopic effort to resolve the obstruction was performed without success. Surgical treatment managed to extract the impacted gallstone through an enterotomy after removal into the first part of the jejunum.
doi:10.1155/2013/839370
PMCID: PMC3707284  PMID: 23864977

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