A Case of Cholecystitis Camouflaging Cholangiocarcinoma.

Cholangiocarcinoma is a malignancy that is hard to detect and resect, due mostly to its location as well as a lack of current screening tests. When found, it is often in the advanced stage as patients are usually asymptomatic during the early course of the disease; the overall prognosis is modest in patients diagnosed at this stage. Here, we discuss the case of a 48-year-old female with no significant past medical history or family history who presented to our hospital with symptoms of acute cholecystitis with a supporting ultrasound. She proceeded to get a laparoscopic cholecystectomy for the same, but an ensuing workup and pathology revealed advanced-stage cholangiocarcinoma. The patient ultimately opted for palliative care given her poor prognosis.

Robotic management of superior mesenteric artery syndrome.

Wilkie's syndrome is an unusual cause of upper intestinal obstruction due to mechanical compression of the superior mesenteric artery (SMA) to the duodenum, with nonspecific symptoms, whose diagnosis is confirmed by angiotomography. Initially, the treatment is conservative to regain weight and restore mesenteric adipose tissue, associated with postural changes of the patient. If this fails, surgical treatment is indicated, being laparoscopic duodenojejunostomy described as the gold standard. Robotics' assistance is feasible and safe to carry out the procedure. We present the case of a 21-year-old male patient who comes with stabbing abdominal pain and persistent postprandial vomiting that has caused weight loss of 11 kilograms in the last 2 years without apparent cause, associated with gastroesophageal reflux. During the procedure, we evidenced open diaphragmatic pillars and duodenal compression due to SMA, and robotic-assisted laparoscopic hyatoplasty + Nissen fundoplication + duodenojejunostomy were performed without complications, with excellent post-surgical results.

Duodenal obstruction: A rare complication of severe acute pancreatitis in children.

Duodenal obstruction (DO) is an uncommon complication of pancreatitis. It has been described in groove and severe acute and chronic pancreatitis in adults but, to the best of our knowledge, it has not yet been reported in pediatric acute pancreatitis. Current guidelines comment on management of several early and late-onset complications, but DO is not mentioned. We describe two patients with acute necrotizing pancreatitis who presented with several complications including walled-off necrosis and DO. In adults, DO is generally managed with adapted nutrition but may require surgical bypass, such as gastroenterostomy. Our patients were managed conservatively and fully recovered 2 months after DO diagnosis. DO may require lengthy hospitalizations and markedly restrict patients' quality of life; however, prolonged conservative treatment was effective in our patients and should be considered even in severe pediatric cases.

Case Presentation of Duodenal Obstruction Caused by Complete Annular Pancreas.

Teaching Point: A complete annular pancreas, a rare congenital anomaly, can lead to duodenal obstruction, causing recurrent symptoms like vomiting and often requiring surgical intervention for relief.

Superior Mesenteric Artery Syndrome: A Misdiagnosed Disorder.

The superior mesenteric artery syndrome also known as Wilkie's syndrome or Benign duodenal stasis, is a condition that occurs when the third duodenum is compressed between the superior mesenteric artery anteriorly and the abdominal aorta posteriorly following the disappearance of the perivascular fatty tissue. It can emulate the symptoms of an upper abdominal obstruction. This case involves a 9-year-old female patient experiencing food vomiting that did not improve with medication. Radiological work-up, which included an abdominal X-ray and a CT angiography, led to the diagnosis of extrinsic and incomplete obstruction of the third duodenum by the aorto-mesenteric clamp. Unfortunately, this diagnosis is rarely made. The purpose of this article is to provide a review of the etiology, clinical presentation, and imaging findings of this syndrome.

Percutaneous insertion of long-covered biliary stents in patients with malignant duodenobiliary stricture.

OBJECTIVE: To investigate the technical feasibility, safety, and efficacy of a long-covered biliary stent in patients with malignant duodenobiliary stricture. METHODS: This retrospective study enrolled 57 consecutive patients (34 men, 23 women; mean age, 64 years; range, 32-85 years) who presented with malignant duodenobiliary stricture between February 2019 and November 2020. All patients were treated with a long (18 or 23 cm)-covered biliary stent. RESULTS: The biliary stent deployment was technically successful in all 57 patients. The overall adverse event rate was 17.5% (10 of 57 patients). Successful internal drainage was achieved in 55 (96.5%) of 57 patients. The median patient survival and stent patency times were 99 days (95% confidence interval [CI], 58-140 days) and 73 days (95% CI, 60-86 days), respectively. Fourteen (25.5%) of the fifty-five patients presented with biliary stent dysfunction due to sludge (n = 11), tumor overgrowth (n = 1), collapse of the long biliary stent by a subsequently inserted additional duodenal stent (n = 1), or rapidly progressed duodenal cancer (n = 1). A univariate Cox proportional hazards model did not reveal any independent predictor of biliary stent patency. CONCLUSIONS: Percutaneous insertion of a subsequent biliary stent was technically feasible after duodenal stent insertion. Percutaneous insertion of a long-covered biliary stent was safe and effective in patients with malignant duodenobiliary stricture. CLINICAL RELEVANCE STATEMENT: In patients with malignant duodenobiliary stricture, percutaneous insertion of a long-covered biliary stent was safe and effective regardless of duodenal stent placement. KEY POINTS: • Percutaneous insertion of long-covered biliary stents in patients with malignant duodenobiliary stricture is a safe and effective procedure. • Biliary stent deployment was technically successful in all 57 patients and successful internal drainage was achieved in 55 (96.5%) of 57 patients. • The median patient survival and stent patency times were 99 days and 73 days, respectively, after placement of a long-covered biliary stent in patients with duodenobiliary stricture.

Infiltrating Lobular Carcinoma of the Breast Metastatic to the Duodenum, about a Case

Introduction: Gastric outlet obstruction or pyloric syndrome can occur secondary to neoplastic involvement, and metastasis as an etiology is unusual. Breast neoplasms generally cause bone, liver, and lung metastases, rarely involving the gastrointestinal tract. Case presentation: A 69-year-old female patient with infiltrating lobular carcinoma of the right breast consulted for abdominal pain and postprandial emetic episodes with oral intolerance and dyspnea. Bilateral neoplastic breast involvement and dilation of the gastric chamber with thickening of the pylorus were recorded. She required antiemetic management and placement of a nasogastric tube. She was taken to an upper digestive tract endoscopy, which found an ulcerated lesion with an infiltrative appearance at the postpyloric level that circumferentially compromised the duodenal lumen. Then, a biopsy was taken, which was compatible with a breast carcinoma of a lobular type. This entity, called pyloric syndrome due to neoplasia, can be managed with gastrojejunostomy or an enteral prosthesis that improves the quality of life of patients with an ominous short-term prognosis. The patient in our case expressed advance directives not to receive invasive procedures, for which an uncovered metal prosthesis was placed for palliative purposes, achieving the re-establishment of the feeding route and resolution of dyspnea due to restriction. Conclusions: The metastatic involvement of neoplasms of the breast to the gastrointestinal tract is rare; however, it should be suspected in elderly patients with previously documented neoplasms.

Introducción: La obstrucción al tracto de salida gástrico o síndrome pilórico puede presentarse de manera secundaria a compromiso neoplásico, y es inusual el compromiso metastásico como etiología. Las neoplasias de la mama generalmente originan metástasis óseas, hepáticas y pulmonares, y es infrecuente el compromiso del tracto digestivo. Presentación del caso: Se trata de una paciente de 69 años con carcinoma lobulillar infiltrante de mama derecha que consultó por dolor abdominal y episodios eméticos posprandiales con intolerancia a la vía oral y disnea. Se registró un compromiso neoplásico mamario bilateral y dilatación de la cámara gástrica con engrosamiento del píloro. Se dio manejo antiemético y colocación de sonda nasogástrica. Fue llevada a una endoscopia de vías digestivas altas en la que se encontró una lesión ulcerada de aspecto infiltrativo a nivel pospilórico que comprometía de forma circunferencial la luz duodenal, y luego se tomó una biopsia a este nivel, que fue compatible con un carcinoma mamario de tipo lobulillar. Esta entidad, denominada síndrome pilórico por neoplasias, puede manejarse con gastroyeyunostomía o con prótesis enteral que mejore la calidad de vida en pacientes con pronóstico ominoso a corto plazo. La paciente de nuestro caso manifestó voluntades anticipadas para no recibir procedimientos invasivos, por lo cual se ofreció la colocación de una prótesis metálica descubierta con fines paliativos y se logró el restablecimiento de la vía de alimentación y resolución de la disnea por restricción. Conclusiones: El compromiso metastásico de neoplasias de la mama al tracto digestivo es poco frecuente; sin embargo, debe sospecharse en pacientes de edad avanzada y con neoplasias previamente documentadas.

Congenital duodenal web causing partial obstruction with recurrent vomiting and abdominal distention in a toddler boy: a case report.

BACKGROUND: The duodenal web is a thin, elongated, web-like structure that is one of the factors contributing to duodenal obstruction. Only 100 cases have been reported in the literature. We present a 2.5-year-old cachectic Afghan child who did not have any overt signs and symptoms of intestinal obstruction, like recurrent vomiting, abdominal distention, and weight loss. The web was discovered near the intersection of the third and fourth portions, which is an uncommon location for the duodenal web. The late presentation of congenital duodenal web with partial obstruction is rare but well-known and has been reported in this case. CASE PRESENTATION: A 2.5-year-old cachectic Afghan child who had recurrent vomiting and experienced abdominal distention was brought to Maiwand Teaching Hospital from the Jabelsuraj region of Parwan province. The patient was suffering from unusual signs and symptoms like recurrent vomiting, abdominal distention, weight loss, and constipation. The diagnosis of these anomalies was established by a detailed history, clinical features, and abdominal CT scan. In the computerized tomography scanning (CT-Scan) image reported, there was a web with stenosis and partial obstruction in the distal aspect of the third-to-fourth portion of the duodenum. After preoperative stabilization, the child was taken for surgery. The abdomen was opened by a right upper abdominal transverse incision. After web resection and duodenoplasty, the patient was shifted to the recovery room in satisfactory condition. The child was allowed to feed after 8 days, which he tolerated well. CONCLUSION: Congenital duodenal web with partial obstruction is typically observed in the second and third years of life. It is suspected in patients with recurrent vomiting, abdominal distention, weight loss, and constipation. Partial obstruction may not have an overt presentation, making it a challenging diagnosis for general practitioners. Abdomen X-ray and CT scan usually confirm the diagnosis, and successful surgical intervention is recommended.

Superior mesenteric artery syndrome and anorexia nervosa: a case report.

BACKGROUND: Superior mesenteric artery (SMA) syndrome is an underdiagnosed complication in anorexia nervosa (AN) patients, which results from weight loss-induced atrophy of the mesenteric fat pad, causing compression of the third part of the duodenum. SMA syndrome can be life-threatening as its nonspecific symptomatology often results in a delayed diagnosis. It is a rare condition, but its true prevalence may be higher than the reported numbers. A history of persistent nausea and vomiting after oral intake and weight loss in AN should raise suspicion about this diagnosis, as weight loss is the most significant factor in this diagnosis. Other high-risk factors include rapid, extreme weight loss, anatomical abnormalities, or a history of prior abdominal or spinal surgeries. CASE PRESENTATION: The patient presented in this report was a 26-year-old Caucasian female with a history of severe enduring anorexia nervosa. This patient suffered from an insidious case of SMA syndrome secondary to AN. This patient presented with vague symptoms of nausea and vomiting, persistent abdominal pain, and rapid weight loss. The patient was successfully treated but could have had a much different outcome if the diagnosis had been further delayed. CONCLUSIONS: An awareness of SMA syndrome and its clinical presentation within similar populations can prevent complications and even fatalities that come with it.

Understanding the diagnosis of superior mesenteric artery syndrome: analysis of the location of duodenal impression on upper gastrointestinal studies.

BACKGROUND: Upper gastrointestinal (GI) contrast studies are frequently requested to aid superior mesenteric artery syndrome diagnosis, a rare entity. Compression of the third duodenal part is expected to be mid-to-left of the midline where the superior mesenteric artery arises from the aorta; however, a duodenal impression to the right of the midline due to normal anatomic impression by the inferior vena cava (IVC) is often encountered and frequently misdiagnosed. OBJECTIVE: The purpose of this study was to determine the frequencies of (1) normal right-of-midline duodenal impressions and (2) mid-to-left of midline compressions in upper GI studies in a tertiary pediatric referral center. MATERIALS AND METHODS: All upper GI studies performed at our institution over 2 years were retrospectively evaluated to determine whether the duodenum had vertical duodenal impression to the right of the vertebral midline, mid-to-left of the vertebral midline, or no identifiable duodenal impression at all. RESULTS: In total, 538 upper GI studies were included in this analysis. A total of 275 male and 247 female patients between 0 and 17 years of age (median: 6 years, range: 1 month-17 years) were included. Of 538 total upper GI studies, there were 240 studies (44.6%) with a right-of-midline impression. There were only 10 studies (1.9%) with a mid-to-left of midline compression, and 9/10 also showed a concurrent right-sided impression sign. CONCLUSION: Right-of-midline duodenal impression is a normal anatomic finding caused by the IVC and should not be confused with superior mesenteric artery syndrome. In the presence of an appropriate clinical context, proximal duodenal dilation, "to-and-fro" motion of contrast, and duodenal impression at mid-to-left of midline, a diagnosis of superior mesenteric artery syndrome should be considered.

Síndrome de la arteria mesentérica superior o Síndrome de Wilkie. Presentación de tres casos clínicos y revisión de la literatura

Objetivo: Presentar una causa rara de obstrucción duodenal como es el sindrome de arteria mesentérica superior (SAMS). Material y Método: se presentan tres casos clínicos de sindrome de SAMS. Resultados: el tratamiento médico y nutricional fue exitoso en los primeros dos casos, mientras que en el último fue necesario realizar una derivación quirúrgica. Discusión: en este sindrome, el ángulo aortomesentérico normal se encuentra disminuído, causando la compresión de la tercera porción del duodeno entre la aorta y la arteria mesentérica superior. Esto determina una obstrucción duodenal que se ve más frecuentemente en pacientes con pérdida importante y rápida de peso. Esto determina alteraciones hidroelectrolíticas y desnutrición severas. El tratamiento médico consiste en soporte nutricional y corrección de anormalidades hidroelectrolíticas. Los procedimientos quirúrgicos se reservan frente a los casos de falla del tratamiento médico. Conclusión: el SAMS es una entidad poco frecuente y un reto diagnóstico. El cuadro clínico puede ser grave con desnutrición severa y trastornos hidroelectrolíticos que ponen en riesgo la vida del paciente. El soporte hidroelectrolítico y nutricional, junto a la duodenoyeyunostomía, son los tratamientos de elección.

Aim: To present a rare cause of duodenal obstruction known as the superior mesenteric artery syndrome (SMAS). Material and Method: we present three cases of SMAS. Results: medical and nutritional treatment were effective in the first two cases while in the last case, a derivative procedure was necessary. Discussion: in this syndrome, the normal aortomesenteric angle is narrowed, causing compression of the third portion of the duodenum between the aorta and the superior mesenteric artery. This leads to duodenal obstruction more frequently observed in patients with severe and fast weight loss. Medical treatment consists in nutritional support and correction of hydro electrolyte imbalance. Surgical procedures are reserved for cases with failure of medical treatment. Conclusion: SMAS is a rare entity and a diagnosis challenge. Clinical setting may be severe with extreme malnutrition and life-threatening dehydration and electrolyte disorder. Nutritional support, hydro electrolyte correction, combined with duodenojejunostomy, if necessary, are the treatments of choice.

Bouveret Syndrome: A Rare Case of Gastric Outlet Obstruction Caused by an Impacted Gallstone.

Bouveret syndrome is a rare condition where a gallstone obstructs the gastric outlet. This report discusses its diagnosis, management, and the need for further research. Prompt recognition is crucial to prevent complications. CT scan with oral contrast aids in diagnosis. Treatment options include conservative measures, endoscopy, or surgery. A multidisciplinary approach is essential for successful management. More research is needed to understand this condition fully.

Robotic modified Strong procedure for superior mesenteric artery syndrome.

Key Clinical Message: The robotic modified Strong procedure is a safe and effective approach for surgical management of superior mesenteric artery syndrome in properly selected patients. Abstract: Superior mesenteric artery syndrome is a rare syndrome of small bowel obstruction resulting from vascular compression of the duodenum. Here we present our modification of a robotic Strong procedure for the surgical management of SMA syndrome. This procedure is a safe and effective approach for management in properly selected patients.

Case report: Duodenal obstruction caused by gastroduodenal artery pseudoaneurysm with hematoma: an unusual case and literature review.

Visceral artery pseudoaneurysm is a rare disease that most commonly occurs in male patients in their 50s, with gastroduodenal artery (GDA) pseudoaneurysm accounting for only 1.5% of these. The treatment options generally include open surgery and endovascular treatment. In 40 cases of GDA pseudoaneurysm from 2001 to 2022, endovascular therapy was the mainstay of treatment in 30 cases, and most of them (77%) were treated by coil embolization. Our case report describes a 76-year-old female patient with a GDA pseudoaneurysm, which was treated by endovascular embolization using liquid embolic agent N-butyl-2-cyanoacrylate (NBCA) alone. This is the first time this treatment strategy has been used for GDA pseudoaneurysm. We demonstrate a successful outcome with this unique treatment. The successful experience of our case may provide a new treatment strategy for this rare disease.

The beneficial effects of the transanastomotic feeding tube in the management of congenital duodenal obstruction: a meta-analysis.

OBJECTIVE: We aimed to assess the evidence on the efficacy and safety of transanastomotic feeding tubes (TAFTs) in neonates with congenital duodenal obstruction (CDO), we conducted a systematic review. MATERIAL AND METHODS: Using the databases EMBASE, PubMed, and Cochrane, we carried out a thorough literature search up to 2022. Studies comparing TAFT + and TAFT - for CDO were included. We applied a random effect model. RESULTS: 505 CDO patients who met the inclusion criteria were selected. The TAFT + group had a shorter time to reach full feeds (weighted mean difference [WMD]: -6.63, 95% confidence interval [CI]: -8.83 - -4.43; p < 0.001) and had significantly less central venous catheter (CVC) insertion (I2 = 85%) (RR: 0.43, 95% CI: 0.19-1.00; p < 0.05). Fewer patients in the TAFT + group received parenteral nutrition (PN) (I2 = 78%) (RR: 0.43, 95% CI: 0.20-0.95; p < 0.05). There was no statistically significant difference in terms of the development of sepsis (I2 = 37%) (risk ratio [RR]: 1.35, 95% CI: 0.52-3.46; p > 0.05). No statistically significant difference was observed in terms of length of stay (I2 = 82%) (WMD: 2.22, 95% CI: -7.59-12.03; p > 0.05) and mortality (I2 = 0%) (RR: 0.55, 95% CI: 0.07-4.34; p > 0.05). CONCLUSIONS: The use of the transanastomotic tube resulted in early initiation of full feeding, less CVC insertion, and less need for PN.

OBJETIVO: Nuestro objetivo fue evaluar la evidencia sobre la eficacia y seguridad de TAFT en recién nacidos con CDO, realizamos una revisión sistemática. MATERIAL Y MÉTODOS: Utilizando las bases de datos EMBASE, PubMed y Cochrane, realizamos una búsqueda bibliográfica exhaustiva hasta 2022. Se incluyeron estudios que compararan TAFT + y TAFT - para CDO. Aplicamos un modelo de efectos aleatorios. RESULTADOS: Se seleccionaron 505 pacientes con ODC que cumplían con los criterios de inclusión. El grupo TAFT + tuvo un tiempo más corto para alcanzar la alimentación completa (DMP -6.63, IC del 95 %: −8.83 a −4.43; p < 0.001) y tuvo una inserción de CVC significativamente menor. Menos pacientes en grupo TAFT + recibieron NP (I2 = 78%) (RR: 0.43, IC del 95%: 0.20 a 0.95; p < 0.05). No hubo diferencia estadísticamente significativa en cuanto al desarrollo de sepsis. No se observaron diferencias estadísticamente significativas en cuanto a la duración de la estancia (I2 = 82 %) (DMP 2.22, IC del 95 %: −7.59 a 12.03; p < 0.05) y mortalidad (I2=0 %) (RR: 0.55, IC del 95 % 0.07 a 4.34; p > 0.05). CONCLUSIONES: El uso de la sonda transanastomótica resultó en el inicio temprano de la alimentación completa, menor inserción de CVC y menor necesidad de NP.

Rare Complication of Strongyloidiasis in Vietnam: A Case of Venous Thromboembolism and Duodenal Obstruction.

Strongyloidiasis, a chronic helminth infection caused by the parasitic nematode Strongyloides stercoralis, has various clinical manifestations. Although rare, duodenal obstructions and venous thromboembolism are possible complications of strongyloidiasis. This paper presents the case of a 47-year-old Vietnamese male with a history of right lower limb edema, anorexia, nausea, vomiting, diarrhea, and abdominal discomfort lasting for four months. Venous Doppler ultrasound detected a thrombus in the right femoral vein, while an abdominal CT scan revealed a mass lesion suggestive of a lower bile duct tumor. Esophageogastroduodenoscopy showed a friable duodenal cap mucosa with multiple ulcers and edematous mucosa of the second part of the duodenum that caused a partial lumen obstruction. The final histological examination of the biopsy specimen revealed chronic duodenitis with larvae consistent with Strongyloides stercoralis. The patient was treated with Ivermectin for two weeks and anticoagulation therapy for three months. After treatment and a six-month follow-up, the patient's gastrointestinal symptoms and leg swelling resolved completely. This is the first documented case of a patient in Vietnam with strongyloidiasis who presented with venous thromboembolism and duodenal obstruction.

Obstrução duodenal por cálculo - síndrome de bouveret: um relato de caso / Duodenal obstruction by calculus - bouveret syndrome: a case report

Introdução: A Síndrome de Bouveret é uma complicação rara, causada por um cálculo biliar grande que obstrui o intestino por meio de uma fístula e tem como principais sintomas: náuseas, vômitos, dor abdominal e distensão. O diagnóstico é feito por meio de exames de imagem, o tratamento é desafiador e pode envolver cirurgia ou procedimentos endoscópicos. Tem morbimortalidade considerável, mas a falta de diretrizes padrão dificulta o diagnóstico e o tratamento. Objetivos: Apresentar um relato de caso de paciente com características fisiopatológicas e diagnóstico de Síndrome de Bouveret, discutir a sintomatologia clínica, diagnóstico, tratamento e o desfecho cirúrgico. Método: Relato de caso realizado por revisão de prontuário e exames de paciente com síndrome de Bouveret. Apresentação: Feminina, 62 anos, quadro clínico compatível com obstrução duodenal. Tomografia de abdômen: imagem ectópica radiopaca, distensão hidroaérea intestinal, sugerindo cálculo biliar, confirmada através de endoscopia digestiva alta. Submetida a gastrotomia, seguida de gastrorrafia, sem reparo da fístula colecistogástrica. Discussão: Síndrome de Bouveret é mais comum em idosos e mulheres com antecedentes de cálculos biliares grandes. O diagnóstico é feito por meio de exames de imagem, geralmente por tomografia computadorizada e o tratamento visa remover o cálculo e aliviar a obstrução intestinal de maneira menos invasiva possível. Por alto risco cirúrgico, o tratamento endoscópico por meio de métodos como retirada com cesta ou litotripsia é indicado, porém, requer múltiplos procedimentos e possui limitações. A abordagem cirúrgica pode ser realizada em um ou dois tempos, dependendo das condições do paciente. Conclusão: Exames de imagens aliados à clínica são essenciais para o diagnóstico e tratamento com gastrostomia e o reparo de fistula em dois tempos se mostra uma ótima opção

Introduction: Bouveret syndrome is a rare complication, caused by a large gallstone that obstructs the intestine through a fistula and has as main symptoms: nausea, vomiting, abdominal pain and distension. The diagnosis is made through imaging tests, the treatment is challenging and may involve surgery or endoscopic procedures. It has considerable morbidity and mortality, but the lack of standard guidelines makes diagnosis and treatment difficult. Objectives: To present a case report of a patient with pathophysiological characteristics and diagnosis of Bouveret syndrome, to discuss the clinical symptomatology, diagnosis, treatment and surgical outcome. Method: Case report performed by review of medical records and examinations of patients with Bouveret syndrome. Presentation: Female, 62 years old, clinical picture compatible with duodenal obstruction. Abdominal CT scan: radiopaque ectopic image, intestinal hydrorespiratory distension, suggesting gallstone, confirmed by upper digestive endoscopy. Submitted to gastrotomy, followed by gastrorraphy, without repair of the cholecystogastric fistula. Discussion: Bouveret syndrome is more common in the elderly and women with a history of large gallstones. The diagnosis is made through imaging tests, usually by computed tomography and the treatment aims to remove the stone and relieve intestinal obstruction in the least invasive way possible. Due to high surgical risk, endoscopic treatment through methods such as basket removal or lithotripsy is indicated, however, it requires multiple procedures and has limitations. The surgical approach can be performed in one or two times, depending on the patient's conditions. Conclusion: Imaging exams combined with the clinic are essential for diagnosis and treatment with gastrostomy and two-stage fistula repair is a great option

Introducción: El Síndrome de Bouveret es una complicación rara, causada por un gran cálculo biliar que obstruye el intestino a través de una fístula y tiene como síntomas principales: náuseas, vómitos, dolor abdominal y distensión. El diagnóstico se realiza a través de pruebas de imagen, el tratamiento es desafiante y puede involucrar cirugía o procedimientos endoscópicos. Tiene una morbilidad y mortalidad considerables, pero la falta de pautas estándar dificulta el diagnóstico y el tratamiento. Objetivos: Presentar un reporte de caso de un paciente con características fisiopatológicas y diagnóstico de Síndrome de Bouveret, discutir la sintomatología clínica, diagnóstico, tratamiento y resultado quirúrgico. Método: Reporte de caso realizado mediante revisión de historias clínicas y exámenes de un paciente con síndrome de Bouveret. Presentación: Mujer, 62 años, cuadro clínico compatible con obstrucción duodenal. Tomografía de abdomen: imagen ectópica radiopaca, distensión intestinal hidroaérea, sugestiva de cálculos biliares, confirmada por endoscopia digestiva alta. Sometido a gastrotomía, seguida de gastrorrafia, sin reparación de la fístula colecistogástrica. Discusión: El síndrome de Bouveret es más común en ancianos y mujeres con antecedentes de cálculos biliares grandes. El diagnóstico se realiza mediante pruebas de imagen, generalmente por tomografía computarizada, y el tratamiento tiene como objetivo eliminar el cálculo y aliviar la obstrucción intestinal de la forma menos invasiva posible. Debido al alto riesgo quirúrgico, está indicado el tratamiento endoscópico mediante métodos como la extracción con canastilla o la litotricia, sin embargo, requiere múltiples procedimientos y tiene limitaciones. El abordaje quirúrgico se puede realizar en una o dos etapas, dependiendo de las condiciones del paciente. Conclusión: Los exámenes de imagen combinados con la clínica son fundamentales para el diagnóstico y tratamiento con gastrostomía y la reparación de fístulas en dos tiempos demuestra ser una gran opción.

Superior Mesenteric Artery Syndrome in an Adolescent Female with Anorexia Nervosa.

Superior mesenteric artery syndrome (SMAS) is a rare condition that develops from compression of the duodenum between the superior mesenteric artery (SMA) and abdominal aorta. SMAS is an atypical complication of restrictive eating disorders. The SMA is supported by adipose tissue to create an aortomesenteric angle that varies from 25-60 degrees. A reduction in adipose tissue causes narrowing of this angle, and SMAS develops when the aortomesenteric angle is narrow enough that it compresses the distal duodenum passing through. Patients present with small bowel obstructive symptoms. We report a severe case of SMAS in an adolescent female with anorexia nervosa who presented with acute and chronic symptoms of bowel obstruction. Awareness of the association between SMAS and restrictive eating disorders can help guide clinical decision-making and prevent delay of diagnosis and serious complications.