Endoscopic ultrasound-guided choledochoduodenostomy versus hepaticogastrostomy combined with gastroenterostomy in malignant double obstruction (CABRIOLET_Pro): A prospective comparative study.

Objectives: Malignant double obstruction, defined as the simultaneous presence of biliary and gastric outlet obstruction, represents a challenging clinical scenario. Previous retrospective experiences have demonstrated shorter dysfunction-free survival (DyFS) of endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) versus EUS-hepaticogastrostomy (EUS-HGS) in this setting, but no prospective evidence is available. Methods: Twenty consecutive patients with malignant double obstruction, treated with EUS-gastroenterostomy (and EUS-guided biliary drainage, following a previously failed ERCP, were enrolled in a prospective observational study (ClinicalTrials.gov NCT04813055) comparing EUS-CDS versus EUS-HGS. Efficacy and safety were evaluated, with Biliary Dysfunctions as the primary outcome and DyFS using Kaplan-Meier estimates as a primary measure. Results: Twenty patients (75% with pancreatic cancer, 50% with metastatic disease) with EUS-gastroenterostomy were included (seven EUS-CDS and 13 EUS-HGS). No significant difference was detected at baseline. Technical success was 100% in both groups. EUS-CDS compared to EUS-HGS showed similar clinical success (100% vs. 92.3%, p = 0.5), a higher rate of post-procedural adverse events (42.9% vs. 7.7%, p = 0.067, mostly related to severe/fatal cholangitis in the EUS-CDS group) and a higher rate of biliary dysfunctions during follow-up (71.4% vs. 16.7%, p = 0.002).DyFS was significantly shorter in the EUS-CDS group (39 [15-62] vs. 268 [192-344] days, p = 0.0023), with a 30-days DyFS probability of 57.1% vs. 100% (hazard ratio = 7.8 [1.4-44.2]). Conclusions: In this prospective comparison of patients with malignant double obstruction undergoing EUS-gastroenterostomy, treating jaundice with EUS-CDS versus EUS-HGS resulted in a reduced probability of survival without biliary events and an increased risk of biliary dysfunctions (number needed to harm = 1.8), with detection of severe/fatal cholangitis.

Lumen-apposing metal stents for anastomosis creation throughout the gastrointestinal tract: A large single-center experience.

Objectives: The introduction of lumen-apposing metal stents (LAMSs) has revolutionized the field of therapeutic endoscopic ultrasound. This study aims to evaluate the efficacy and safety of LAMS in creating an endoscopic ultrasound-guided anastomosis between two segments of the gastrointestinal (GI) tract. Methods: Data from all consecutive LAMS procedures for anastomosis creation between two segments of the GI, conducted between October 2019 and February 2024, were retrospectively analyzed for technical success (defined as correct deployment of the LAMS in the target), clinical success (defined as achievement of the intended clinical goal), and adverse events. Results: A total of 145 LAMS procedures were performed in 136 patients. Indications for LAMS procedures included the need for endoscopic access to or reversal of surgically excluded segments of the GI tract (n = 73, 50.3%), and the alleviation of any GI outflow obstruction (n = 72, 49.7%). The overall technical and clinical success rates were very high (97.2% and 95.2%, respectively). Adverse events were observed in 20/145 (13.8%) cases, including 11 (7.6%) minor events (AGREE <3) and nine (6.2%) major events (AGREE ≥3). Major events included stent migration (n = 1), persisting fistula (n = 3), and bleeding (n = 4). All adverse events were successfully managed, and there were no procedure-related deaths. Loss of LAMS patency occurred in 4/145 (2.8%) cases and could be endoscopically managed in all cases. Conclusions: The creation of anastomoses with LAMS between two segments of the GI tract appears to be effective and safe, with a low reintervention rate due to loss of LAMS patency.

Endoscopic Management of Dysfunctioning Gastric Band after Sleeve Gastrectomy with the Luso-Cor® Esophageal Stent.

Sleeve gastrectomy (SG) can be aided by the addition of a calibration silicone ring, banded SG (BSG). It provides better weight loss than non-banded SG but with higher rate of adverse events. The aim of this case report is to further contribute to the knowledge of how to endoscopically manage these patients by placing a new esophageal stent (Luso-Cor®). A 58-year-old female with grade III obesity (weight 110 kg, BMI: 45.2 kg/m2) underwent SG in 2013. Due to the limited weight loss, a surgical calibration silicon ring was placed in 2017. In the following months, she developed recurrent and abundant postprandial regurgitation, achieving a minimum weight of 66 kg (BMI: 27.1 kg/m2). Gastroesophageal transit showed a stricture at the junction of the gastric corpus and antrum, causing gastric outlet obstruction. Endoscopy identified a regular luminal stenosis with normal mucosa, which allowed easy passage of the endoscope with slight pressure. Two sessions of endoscopic dilatation were performed, first with an 18-mm through-the-scope balloon and later with a 30-mm pneumatic balloon without symptomatic relief. A two-step endoscopic therapeutic approach was proposed to first promote intragastric ring erosion by placing a new partially covered metallic stent, Luso-Cor® esophageal stent 30/20/30 × 240 mm, and subsequently retrieve the stent, followed by cutting and retrieval of the ring. The proximal flare with a 30 mm diameter was placed in the distal esophagus and the distal edge in the prepyloric antrum. However, 2 weeks later, she complained of vomiting and abdominal fullness. Complete migration of the proximal flare of the stent into the remnant gastric fundus was seen on the contrast study. Endoscopy was performed, and the stent was easily removed. A blue calibration ring, partially eroded into the gastric lumen, was observed at the site of gastric tube stenosis. After stent removal, the patient was asymptomatic, and so conservative follow-up was decided. A follow-up endoscopy, performed 5 months later, showed complete reepithelization of the eroded ring. The patient remains asymptomatic after 3 years of follow-up and has regained weight up to 76 kg (BMI: 31.2 kg/m2). The efficacy of endoscopy on the management of ring-related adverse events has been previously reported. Small-case series describe the use of multiple pneumatic dilations or the deployment of plastic or covered metallic stents to cause erosion of the overlying mucosa, followed by cutting and retrieval of the ring. In conclusion, we believe that the mural pressure exerted by the Luso-Cor® esophageal stent, in the limited period it remained in situ, was sufficient to relieve the luminal pressure of the silicon ring, realigning the ring with the remnant gastric tube. This rare clinical entity highlights the potential role of specific metallic stents in the management of these patients.

A cirurgia bariátrica de gastrectomia vertical (sleeve gástrico) pode ser complementada pela adição de um anel restritivo de silicone ­ sleeve gástrico com anel de silastic. O acréscimo deste anel promove uma maior perda de peso, no entanto está associado a maior risco de eventos adversos. O objetivo da apresentação deste caso é contribuir para as diferentes técnicas úteis no tratamento das complicações relacionadas com o anel, através da utilização de uma prótese esofágica (Luso-Cor®).Uma doente de 58 anos, com obesidade grau III (peso 110 kg, IMC 45,2 kg/m2), foi submetida a um sleeve gástrico em 2013. Não apresentou perda de peso favorável e, em 2017, foi colocado um anel de silicone rodeando o tubo gástrico. Nos meses seguintes desenvolveu regurgitação pós-prandial recorrente e abundante, alcançando um peso mínimo de 66 kg (IMC 27,1 kg/m2). Realizou um trânsito gastroesofágico que revelou uma estenose na junção do corpo com o antro gástrico, com evidência de obstrução do esvaziamento gástrico. A endoscopia digestiva alta identificou uma estenose regular recoberta por mucosa sem lesões, com passagem do aparelho após pressão ligeira. Foram realizadas duas sessões de dilatação, inicialmente com balão trough-the-scope de 18 mm e posteriormente com balão pneumático de 30 mm. Os sintomas persistiram e, por esse motivo, foi decidido uma abordagem em dois tempos: primeiro promover a erosão intragástrica da banda para depois a seccionar e remover intraluminalmente. Nesse sentido, foi colocada uma prótese metálica esofágica parcialmente coberta, Luso-Cor® 30/20/30 × 240 mm. O segmento proximal da prótese com 30 mm de diâmetro foi colocado no esófago e o bordo distal da prótese ficou no antro pré-pilórico. No entanto, duas semanas depois, a doente queixou-se de vómitos e enfartamento precoce. O estudo radiográfico com contraste revelou migração distal da prótese, com deslocamento do segmento proximal para o corpo gástrico remanescente. A prótese foi removida endoscopicamente sem dificuldade e, na região da estenose, foi observado o anel de silicone parcialmente erosionado para o lúmen gástrico. Após remoção da prótese a doente evoluiu favoravelmente, sem novos sintomas, e, por esse motivo, foi decido seguimento sem novas intervenções. A endoscopia de seguimento, realizada cinco meses após, demonstrou reepitelização completa do anel parcialmente erosionado. A doente permanece assintomática após três anos de seguimento e voltou a ganhar peso (peso atual 76 kg, IMC 31,2 kg/m2). A eficácia da resolução endoscópica de estenoses relacionadas com anel de silicone no sleeve gástrico já foi relatada. Pequenas séries de casos utilizaram múltiplas sessões de dilatação com balão pneumático ou colocação de próteses plásticas ou metálicas cobertas para promover erosão intragástrica do anel e sua remoção. Acreditamos que a pressão mural exercida pela prótese Luso-Cor®, no curto tempo em que permaneceu in situ, foi suficiente para aliviar a obstrução, realinhando o seu diâmetro com o restante tubo gástrico. Através do relato desta entidade clínica rara, esperamos contribuir para o conhecimento das próteses metálicas específicas para o manejo destes doentes.

Is endoscopic ultrasound-guided gastroenterostomy better than surgical gastrojejunostomy or duodenal stenting?

OBJECTIVES: Gastrojejunostomy is a critical procedure for managing gastric outlet obstruction. While surgical gastrojejunostomy has traditionally been the standard approach, endoscopic ultrasound (EUS)-guided gastroenterostomy has emerged as a promising endoscopic alternative. This comprehensive review aims to explore the development, techniques, outcomes, and comparative effectiveness of EUS-guided gastroenterostomy in comparison to duodenal stenting and surgical gastrojejunostomy. METHODS: A comprehensive literature search was conducted using electronic databases to identify relevant studies published up to April 2024. The search included keywords related to EUS-guided gastrojejunostomy, surgical gastrojejunostomy, and duodenal stenting. Studies reporting on technical success, clinical success, complications, recurrence rates, quality of life, and long-term outcomes were included for analysis. RESULTS: The development of EUS-guided gastroenterostomy has evolved significantly over the years, driven by device advancements and improved endoscopic techniques. Comparative studies have shown that the technique offers several advantages, including the ability to create an anastomosis without the need for surgery, reduced invasiveness, shorter hospital stays, and potentially improved patient outcomes as compared to duodenal stenting and surgical gastrojejunostomy. CONCLUSION: Endoscopic ultrasound-guided gastroenterostomy represents a promising alternative to surgical gastrojejunostomy and duodenal stenting for the management of gastric outlet obstruction. The technique has evolved significantly, offering a less invasive and more effective treatment option.

Epigastric anterior abdominal wall hernia: An unusual cause of gastric outlet obstruction.

A 79-year-old female presented with a 3-week history of dysphagia and vomiting, and an upper abdominal mass which had increased in size over the previous 2 weeks. CT scan showed a partial gastric outlet obstruction secondary to an epigastric hernia. This was assessed further on fluoroscopy, showing the distal stomach in the hernial sac and a delay in gastric emptying. We present the CT and fluoroscopic findings of this rare cause of gastric outlet obstruction.

Interferon-gamma release assays as a tool for differential diagnosis of gastrointestinal tuberculosis.

In this editorial, we comment on an article published in a recent issue of the World Journal of Clinical Cases. There is a pressing need for reliable tools for diagnosing tuberculosis (TB) of the gastrointestinal tract. Despite advancements in the diagnosis and treatment, TB remains a global health challenge. Ali et al demonstrated that TB may mimic gastrointestinal conditions, such as gastric outlet obstruction, causing a delay in the diagnosis. Furthermore, the latter complication is frequently observed during infections, including Helicobacter pylori, and rarely is related to TB, as in the presented case. In line with this, we think that laboratory tests based on interferon-gamma release assays can be a helpful tool for diagnosing latent TB paced in the gastrointestinal tract. Innovative strategies and approaches for diagnosing latent/active extra pulmonary TB are crucial for establishing the diagnosis early and enhancing treatment strategies to mitigate the global burden of TB.

Endoscopic ultrasound-guided gastrojejunostomy with wire endoscopic simplified technique: Move towards benign indications (with video).

OBJECTIVES: Endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ) is an alternative to duodenal stenting and surgical GJ (SGGJ) in malignant gastric outlet obstruction (MGOO). European Society of Gastrointestinal Endoscopy guidelines restricted EUS-GJ for MGOO only, because of misdeployment. The aim was to evaluate its outcomes focusing on benign indications. METHODS: This was a retrospective study conducted from 2016 to 2023 in a tertiary center. Patients included had malignant or benign GOO indicated for EUS-GJ. Techniques were the direct approach until August 2021, and the wire endoscopic simplified technique (WEST) afterwards. The main objective was to compare outcomes in benign vs. MGOO. Secondary end-points were technical success, adverse events rates, and describing the evolution of techniques and indications. RESULTS: In all, 87 patients were included, 46 men, mean age 66 ± 16.2 years. Indications were malignant in 60.1% and benign in 39.1%. The EUS-GJ technique was direct in 33 patients (37.9%) and WEST in 54 (62.1%). No difference was found in terms of technical, clinical, or adverse events rates. The initial technical success rate was 88.5%. The final technical and clinical success rates were 96.6% and 94.25%, respectively. In the last year, benign exceeded malignant indications (70.4% vs. 29.6%, P < 0.05). Seven misdeployments occurred, six being addressed with the rescue technique. The misdeployment rate was significantly decreased using the WEST approach compared to the direct one: 3.7% vs. 18% (P < 0.05). The severe postoperative adverse events rate was 2.3%. CONCLUSION: This study demonstrated similar outcomes of EUS-GJ between benign and MGOO, with a decreasing misdeployment rate (<4%) applying WEST. This represents an additional step towards recommending EUS-GJ in benign indications.

Surgical Palliation for Advanced Pancreas Cancer.

To provide optimal care in pancreatic ductal adenocarcinoma, involvement of palliative medicine and nutritional support is recommended. Advances in endoscopy have resulted in robust options for biliary and gastrointestinal stenting for relief of obstruction. Notwithstanding, surgical hepaticojejunostomy and gastrojejunostomy remain incontrovertible considerations for biliary obstruction and gastric outlet obstruction, respectively. For PDAC-associated pain, opioid therapy continues to be the mainstay. However, refractory pain may be treated with interventional procedures such as celiac or splanchnic nerve blocks or neurolysis. In patients with PDAC, enteral nutrition can be further complicated by exocrine pancreatic insufficiency, which should be treated with oral pancreatic enzyme supplementation.

Adhesive duodenal obstruction: a report of a previously undescribed pathology.

Adhesive small bowel obstruction is thought to be a disorder limited to the jejunum and ileum. As a result, the list of aetiologies for duodenal obstruction does not include adhesions. We report the case of a patient who presented with gastric outlet obstruction (GOO), but with no lesions identified on cross-sectional imaging or endoscopy. Laparoscopy revealed duodenal adhesions as the cause of her GOO. Kockerization of the duodenum led to resolution of her symptoms. This previously undocumented finding leads us to suggest that laparoscopy should be considered in patients who have features highly suspicious for GOO, but have no cause identified on investigation.

Efficacy and safety of self-expandable metallic stents for management of benign gastric outlet obstruction-A prospective study.

INTRODUCTION: We aimed at evaluating the safety and efficacy of self-expandable metallic stent (SEMS) insertion for managing patients with benign gastric outlet obstruction (GOO). METHODS: This prospective interventional study included 23 patients. All consecutive treatment-naïve symptomatic patients with benign GOO were recruited. Fully covered SEMS were deployed across the stricture under fluoroscopic and endoscopic guidance. Technical success, clinical success and sustained treatment response (STR) were assessed. Technical success was defined as the successful deployment of SEMS at the desired anatomic location. Clinical success was defined as the resolution of symptoms and an increase in Gastric Outlet Obstruction Scoring System (GOOSS) of at least 1 point from the baseline score on Day 7. STR was assessed at four and eight weeks post stent removal in patients who had a response at week four. Factors associated with stent migration and non-response at week four were also assessed. RESULTS: The median age of the study population was 30 years (range 19-65 years). Males constituted 65.22%. Most patients presented with vomiting (100%) and abdominal pain (95.65%). Peptic stricture was most common etiology for GOO (60.9%) followed by tubercular (26.1%) and corrosive (13%). Most common site of obstruction was junction of first and second part of duodenum (69.57%) followed by pyloric (30.43%). Median length of stricture was 2 cm (range 1.5-4). Technical success was achieved in all 23 patients (100%). Clinical success was achieved in 21 patients (91.3%). Response at Day 28 was seen in 20 patients (86.95%). Eighteen of 20 (90%) patients who had a response at week four had STR at week four and week eight after stent removal. Stent migration occurred in five (21.7%) patients. On univariate analysis, stricture length, calibre and stent length were found to predict migration. CONCLUSIONS: Fully covered SEMS was an effective and safe management modality in patients with benign GOO. Stent migration remains a troublesome disadvantage.

Unveiling hidden outcomes in malignant gastric outlet obstruction research - insights from a "Pancreas 2000" review.

Malignant gastric outlet obstruction (mGOO) is a major condition affecting patients with periampullary tumors, including pancreatic cancer. The current treatment options include surgical gastroenterostomy, endoscopic stenting and more recently EUS-guided gastroenterostomy. Most studies comparing the outcomes of the three procedures focus on technical success, clinical success and safety. Several "occult" outcomes relevant to the patient's viewpoints and perspective may ultimately impact on cancer-related and overall survival, such as body mass composition, nutritional biomarkers, chemotherapy tolerance and patient-reported quality of life. The aim of this review is to provide an overview of potential key outcomes that should be explored in future comparative research around mGOO treatment options.

Bouveret Syndrome: Etiology, Clinical Presentation, Differential Diagnosis, Complications, and Treatment Options.

Bouveret syndrome is one of the complications of gallstone disease possibly fatal, which proposes the presence of a large stone obliterating the lumen of the duodenum or stomach because of the formation of a bilioenteric fistula. This review article, therefore, plans to review the causes, patient characteristics, diagnostic workup, associated conditions, and treatment of Bouveret syndrome. A literature search was also performed through scientific databases such as Scopus, Google Scholar, and PubMed concerning articles related to Bouveret syndrome written by different authors. The terms employed for the search were bilioduodenal fistula, Bouveret syndrome, gastric outlet obstruction, and gallstone ileus. Both case reports and systematic reviews that were written in the English language and published between the years 2000 and 2024 were considered. Finally, the review establishes the relevant concerns surrounding the diagnosis of Bouveret syndrome, focusing on the diagnosing issues. It emphasises the need for some specialities' involvement and focuses on the importance of endoscopic intervention. For patients, endoscopy remains the first line of treatment, while surgery is necessary in cases where conservative methods cannot be used. The article also focuses on new approaches to treating the conditions, such as percutaneous gallbladder stone dissolution. Latterly, further developments in minimally invasive surgery pertain to refining methods, including endoscopic removal and lithotripsy, to improve the survival rate of patients. Further investigation is required, especially regarding the administration schedule in relation to this disorder and goals that can reduce mortality and morbidity, especially in elderly patients with comorbid diseases.

Swallowed secrets - Plastic bezoar-induced gastric outlet obstruction in a 14-year-old girl: A case report.

INTRODUCTION: Gastric outlet obstruction (GOO) is a rare but serious condition that can arise from various etiologies, including foreign body ingestion. We present a unique case of GOO in a 14-year-old girl resulting from the accumulation of plastic materials, known as a plastic bezoar, due to pica behavior. CASE PRESENTATION: A 14-year-old girl with a history of pica presented with symptoms suggestive of acute gastric obstruction. Imaging studies revealed the presence of a large foreign body extending from the stomach to the jejunum, consistent with a plastic bezoar. Despite attempts at endoscopic removal, surgical intervention was ultimately required due to the size and location of the bezoar. DISCUSSION: This case underscores the challenges associated with diagnosing and managing gastric outlet obstruction secondary to plastic bezoar formation, particularly in pediatric patients with underlying pica behavior. The diagnostic workup involved a multidisciplinary approach, including imaging studies and endoscopic evaluation. Surgical intervention, although invasive, proved necessary for definitive treatment in this case. Postoperative care focused on monitoring for complications and addressing the underlying pica behavior through psychological intervention and support. CONCLUSION: This case highlights the importance of early recognition, thorough diagnostic evaluation, and prompt intervention to prevent complications and ensure favorable outcomes. Collaborative efforts between medical and surgical teams are essential for the comprehensive management of such cases, emphasizing the need for tailored approaches to address both the physical and psychological aspects of care.

Benign pyloric adenomyoma presented as gastric outlet obstruction: a case report and review of the literature.

BACKGROUND: Gastric adenomyoma is a rare benign tumor composed of glandular structures and smooth muscle fibers. While some classify gastric adenomyoma as a hamartoma, others view it as an abortive form of heterotopic pancreas. Despite its benign nature, there is a risk of malignant transformation. Predominantly found in the antrum, gastric adenomyoma affects all ages but is most common in adults aged 40-60 years. Symptoms are nonspecific, and its similarity to other lesions complicates diagnosis. This paper aims to provide a review of medical literature on gastric adenomyoma and its diagnosis and treatment methods, along with presenting an additional case report on the same topic. CASE PRESENTATION: We present the case of a 55-year-old Syrian man who experienced vomiting, weight loss, and chronic partial constipation. An obstructing mass in the pylorus was detected, and then an open surgery was performed to excise the lesion. A biopsy of the resected mass was obtained for histopathological examination. The final diagnosis of the lesion was pyloric-region adenomyoma with severe pyloric stenosis. After the successful surgery, the patient recovered without any recurrence or complications. CONCLUSIONS: Several diagnostic approaches are available, including radiological studies, endoscopic examination, and fine needle aspiration guided by endoscopic ultrasonography. Treatment options involve endoscopic submucosal dissection and complete laparotomy resection. Further studies and thorough reviews are recommended to better understand the best clinical practices. Practitioners should consider gastric adenomyoma when encountering a mural gastric lesion.

This is a successful removal of more than 450 pieces of metal objects from a patient's stomach: a case report.

BACKGROUND: Ingestion of foreign bodies may be seen unconsciously or intentionally in patients with mental health problems. Most cases pass through the esophagus slowly; however, in some cases, the tumor may be located in narrower areas of the digestive tract that require endoscopic or surgical intervention. This study describes a rare case of successful removal of more than 450 pieces of metal objects from the stomach of a 36-year-old man via ingestion of foreign bodies at Imam Khomeini Hospital in Ahvaz. CASE PRESENTATION: A 36-year-old male patient (Aryan race) presented with complaints of chronic abdominal pain, frequent vomiting, and intolerance to liquids and food. The patient's companions mentioned a history of gradual ingestion of small metal objects 3 months prior. The patient was conscious and had stable vital signs. In the patient's X-ray and endoscopy, multiple metal objects inside the patient's stomach were observed, causing gastric outlet obstruction. The patient underwent gastrostomy surgery, and 452 screws, nuts, keys, stones, and other metal parts weighing 2900 g were removed from the stomach. Five days after the operation, the patient was transferred to the psychiatric service in good general condition and was diagnosed with psychosis, and her condition returned to normal at follow-up. CONCLUSION: Successful removal of this foreign body is rare. In chronic abdominal pain, especially in the context of psychiatric disorders, attention should be given to the ingestion of foreign bodies. In swallowing large amounts of sharp and metallic foreign objects, surgical intervention is necessary, especially in cases of obstruction, and saves the patient's life.

Extensive inflammatory adhesion of small bowel with massive Pneumatosis Intestinalis in a patient with gastric outlet obstruction: A rare case report.

INTRODUCTION: Pneumatosis Intestinalis (PI) is a rare disease, majority of which are self-limited processes, in which the intestinal sub mucosa and sub serosa are filled with gas-filled cysts. The exact cause and pathogenesis is not well known yet but there are different theories. The two well accepted fundamental pathogenesis is: mechanical and bacterial. CASE PRESENTATION: Here we report a case of a 25 years old patient presented with history of persistent vomiting, intermittent abdominal cramp and significant weight loss over three months. The primary diagnosis was made as gastric outlet obstruction with concomitant small bowel extensive PI. DISCUSSION: Primary PI has no known cause while secondary type has proposed underlying pathologies with different theorized pathogenesis. The current case report has an underlying pathology of long standing peptic ulcer disease with recent diagnosis of gastric outlet obstruction in favor of the mechanical theory. PI has a broad spectrum of clinical symptoms; ranges from asymptomatic patients to non-specific gastrointestinal symptoms like diarrhea, abdominal distention, weight loss, bloody or mucous stool. Patients with underlying pyloric stenosis, peptic ulcer disease presents with more of upper GI symptoms. Conservative management is usually the treatment of choice. However, surgery must be considered if peritoneal irritation or bowel obstruction appears overt. CONCLUSION: Concomitant occurrence of gastric outlet obstruction with small bowel PI is not uncommon disease but severe and extensive inflammatory adhesion was rarely reported. Therefore surgical intervention is mandated for the former or both depending the severity of the PI.

A rare differential diagnosis of inflammatory bowel disease in a young male patient; a challenging case report.

Background: Chronic granulomatous disease (CGD) is a rare disorder normally diagnosed in infancy. Case presentation: A 27-year-old man admitted with non-specific symptoms of CGD first underwent endoscopy, and colonoscopy procedures as primary evaluation of clinical presentation. Eighteen months after the first admission, he was referred to the emergency department for hematemesis, and critical situations, such as a severe anemic with Hgb= 2.6 mg/dl. As a result of this specific clinical presentation, urgent emergency treatment was performed, and endoscopic examination revealed ulcers and abnormalities in the duodenal bulb and jejunum. Other imaging procedures, such as sonography, and abdominal CT scans, showed splenomegaly. He underwent splenectomy, and after that, endoscopic treatment with balloon TTS dilation was scheduled, but this procedure failed. So, we decided to do a gastro-jujenostomy that alleviated the clinical symptoms. After nine months, he was referred to GOO, and endoscopic evaluation showed giant ulceration with severe stricture in the duodenum, and a polyp in the jejunostomy. Finally, Based on clinical presentation and pathologic evidence of biopsies, the patient approached CGD as the final diagnosis. Conclusion: Step-by-step, rule out of different highly suspicious diseases may result in a definite CGD diagnosis, and rapid management of these patients may increase the chance of survival.

Extensive Cytomegalovirus Gastroduodenitis Causing Gastric Outlet Obstruction in an Immunocompetent Patient.

Cytomegalovirus (CMV) has been extensively researched in immunocompromised people, causing conditions such as colitis, retinitis, esophagitis, encephalitis, and pneumonitis. However, there are limited data on how the disease presents itself in immunocompetent hosts, apart from a self-limited mononucleosis-like syndrome. This case report presents CMV gastroenteritis causing gastroduodenal obstruction in an immunocompetent woman. It is important to consider CMV as a potential cause of various gastric pathologies in immunocompetent people. Further research is necessary to establish guidelines for diagnosing and treating this pathogen.

Bouveret syndrome preceding classical gallstone ileus: a rare presentation of a cholecystoduodenal fistula.

Bouveret syndrome is the rarest variant of gallstone ileus characterized by the passage and impaction of a gallstone through a bilioenteric fistula leading to gastric outlet obstruction. The documented movement of an impacted gallstone in Bouveret syndrome through the gastrointestinal tract has not been previously discussed in the literature. A 64-year-old man presented with acute on chronic epigastric pain, fevers, and vomiting. Abdominal computed tomography established a diagnosis of Bouveret syndrome. A trial of endoscopic gallstone extraction was unsuccessful. Laparoscopic gastrotomy and stone removal were later attempted, however, intraoperatively it was noted that the stone had migrated and was now impacted in the jejunum causing a small bowel obstruction. The clinical picture was now that of gallstone ileus. Laparoscopic enterolithotomy was performed successfully. This article discusses the radiological, endoscopic, and intraoperative findings in this rare case of Bouveret syndrome that had evolved into classical gallstone ileus following stone migration.

[Treatment Strategies for Gastric Cancer Patients with Gastric Outlet Obstruction].

Gastric cancer frequently leads to gastric outlet obstruction (GOO), causing significant symptoms and complications. Surgical bypass and stenting are two representative palliative treatments for GOO by gastric cancer. This study reviews clinical guidelines for malignant GOO treatment, highlighting differences in recommendations based on patient survival expectations and systemic health. A meta-analysis of surgical bypass and stenting in gastric cancer patients revealed no significant difference in technical and clinical success rates between the two treatments. However, stenting allowed faster resumption of oral intake and shorter hospital stays but had higher rates of major complications and reobstruction. Despite these differences, overall survival did not significantly differ between the two groups. Emerging techniques like EUS-guided gastrojejunostomy show promise but require further research and experienced practitioners. Ultimately, treatment should be tailored to patient preferences and the specific benefits and drawbacks of each method to improve quality of life and outcomes.