Finsterer- Bancroft-Plenk operation and Bouveret's syndrome: a rare association.

INTRODUCTION: Bouveret syndrome is an extremely rare clinical condition caused by gallstone ileus due to cholecystoduodenal or cholecystogastric fistula in the setting of cholecystitis. The impacted gallstone in the duodenum causes gastric outlet obstruction, manifesting as epigastric pain, nausea, and vomiting. Owing to its scarcity of reported cases, diagnosing and treating this syndrome is challenging. Our case report emphasizes the early recognition of a clinical syndrome, which should suggest Bouveret syndrome rather than other causes of gastric outlet obstruction, such as malignancy. CASE DESCRIPTION/METHODS: A 68-year-old female with a past medical history of cholelithiasis and hypothyroidism presented with a 2-day history of epigastric pain. The pain was located in the epigastric region, associated with nausea and vomiting. Labs were non-significant except for mild leukocytosis. CT revealed numerous gallstones with gallbladder wall thickening, along with markedly dilated stomach with pyloric wall thickening showing partial gastric outlet obstruction (GOO) (Figure 1). RUQ ultrasonogram showed WES sign and DISIDA scan showed cystic duct obstruction, CT guided biopsy was done at GB wall and pylorus but was negative for malignancy. EGD showed high-grade pyloric stricture causing a GOO for which NG tube was placed. TPN was initiated and EGD was reattempted on hospital day 9, which showed a small fistulous opening in the gastric antrum along with a gallstone partially filling the duodenal bulb. The gallstone was noted to “ball-valve” in the area with insufflation and suction via the scope. The findings were consistent with Bouveret syndrome, which was corroborated on MRCP (Figure 2). The patient underwent open partial cholecystectomy, repair of cholecystoduodenal fistula, gastrojejunostomy, and enterolithotomy on hospital day 14. Post-operatively, the patient had delayed recovery of gastric function and required prolonged nasogastric tube placement. The recovery was also complicated by Bacteroides Fragilis bacteremia. The patient was eventually discharged on hospital day 29. DISCUSSION: Calculous cholecystitis with gastric outlet obstruction is a clinical situation, which Bouveret syndrome should be considered strongly. Since the majority of patients are old and have other comorbid conditions, the mortality rate is higher than those with other causes of mechanical small bowel obstruction. Maintaining a high level of suspicion can avoid delay in the diagnosis and can lead to timely surgical interventions.Figure 1.: Gallstones filling the gallbladder with wall thickening and pericholecystic fluid. Markedly distended stomach with pyloric wall thickening concerning for GOO.Figure 2.: Cholecystitis with findings suspicious for a cholecystoduodenal fistula and 2.9cm gallstone in the region of the first portion of duodenum, suggestive of Bouverete syndrome.

Bouveret's syndrome is a clinically distinct form of gallstone ileus caused by the formation of a fistula between the gallbladder and duodenum, where typically a large gallstone is impacted in the pylorus or proximal duodenum. This rare condition could be associated with high morbidity and mortality rates, hence increased awareness is waranted. We report a case of Bouveret's syndrome in a patient with gastric outlet obstruction due to a 7 cm gallstone chronically impacted in proximal duodenum. 78-year-old male with history of atrial fibrillation and COPD presented with epigastric pain and bilious vomiting of 1 week duration. Physical exam revealed abdominal distension. Laboratory tests revealed elevated WBCs, liver enzymes and lipase. CT scan of abdomen showed a 7 x 4.4 cm gallstone in proximal duodenum, a cholecystoduodenal fistula and pneumobilia (Figure 1). EGD revealed a complete obstruction secondary to a stone impacted beyond the duodenal bulb (Figure 2). Endoscopic removal was attempted initially, aiming to fragment the stone via mechanical and electrohydraulic (EHL) lithotripsy. The large size was a limitation to the mechanical approach. EHL was partially effective in fragmenting the stone despite using the highest available energy level and multiple catheters. Other tools were attempted thereafter in order to pull the stone in the stomach for further fragmentation, including fluoroscopy assisted wire-guided biliary balloon, assisted TTS dilation balloon extraction, snare assisted and loop assisted removal. The stone was adherent to the wall of the duodenum. The patient underwent successful surgical removal of the stone through duodenotomy (Figure 3) followed by cholecystectomy and cholecystoduodenal fistula repair. Patient did well postoperatively.Figure 1Figure 2Figure 3Bouveret's syndrome is an uncommon cause of gastric outlet obstruction and an important diagnosis worth considering especially in patients with history of biliary colics, large gallstones or chronic cholecystitis. Abdominal imaging and endoscopy are the mainstay of diagnosis. Treatment options include endoscopic and surgical management. Endoscopic removal should always be attempted first, despite the reported limited success rate of 10%. The addition of mechanical and/or electrohydraulic lithotripsy has been used with some success. Surgery is required in over 90% of cases, with mortality rates ranging from 19% to 24%. Surgical options include enterotomy and removal of stone with or without cholecystectomy and repair of fistula, or gastric bypass surgery. In this case we present a unique case of chronic Bouveret's syndrome where the size (7 cm) and adherence of the impacted stone to the duodenal wall was a major limitation hindering the success of the endoscopic approach. Increased clinical awareness is of utmost importance for the timely management of this rare syndrome.

Background: Bouveret's syndrome occurs when a gallstone passes through a cholecystoduodenal fistula (CDF) and obstructs the duodenum resulting in gastric outlet obstruction. It is a rare variant of gallstone ileus with an overall incidence of 1-3%. Bouveret's syndrome poses an unique diagnostic and therapeutic challenge for clinicians due its rarity and unpredictable symptomatology. Case Presentation: An 81 year old female presented with an acute onset of nausea, vomiting and right upper quadrant abdominal pain. Physical examination was unremarkable except for tenderness of the right upper quadrant. No leukocytosis was present. Transaminases were AST 43, ALT 42, alkaline phosphatase 266 and total bilirubin 0.7. Computed tomography of abdomen revealed a CDF with a 4x3cm gallstone in the proximal portion of the duodenum causing obstruction. An upper endoscopy was subsequently performed, revealing a 4cm impacted stone at the junction of the first and second portion of the duodenum, along with a CDF containing a 2cm gallstone. A large stone fragment was successfully retrieved using a lithotripsy basket after performing a 20mm balloon dilation of the pylorus. A second upper endoscopy was performed with the remaining portions of the stone being crushed using an Olympus lithotripter. A magnetic resonance cholangiopancreatography revealed choledocholithiasis with multiple stones and sludge in the distal common bile duct. An endoscopic retrograde cholangiopancreatography was performed, at which time a 15mm biliary sphincterotomy was made and the biliary tree was swept with a 15mm balloon starting at the bifurcation, resulting in complete removal of stones and sludge.Figure 1Figure 2Discussion: The majority of patients with a CDF are elderly with a female preponderance. In about 60% of these cases the fistula is cholecystoduodenal. Typical symptoms of Bouveret's syndrome include nausea, vomiting and epigastric abdominal pain. The pathophysiology of this syndrome results from the increase in intraluminal pressure caused by obstruction, leading to ischemia and necrosis, allowing the gallstone to perforate the gallbladder and intestinal wall. Gallstones larger than 2.5cm usually become impacted in the gastric outlet. Endoscopic intervention with a lithotripsy balloon is a safe and effective first line of treatment for Bouveret's syndrome, considering that the majority of patients are elderly with multiple comorbidities and a high perioperative surgical risk.Figure 3

Background The dyspepsia symptoms including epigastric pain, throbbing pain, fullness, bloating, tenderness, colicky pain, mouth bitterness, heartburn, abdominal pain, vomit and decreased appetite. The dyspepsia symptoms of peptic ulcer and gastroesophageal reflux disease often overlap. Dyspepsia symptoms and disease subtypes in Asian countries were different compared to Western countries. The aim of this study is to discover the association between dyspepsia symptoms in Karawaci, Banten, Indonesia as one of the Asian countries and the diagnosis of peptic ulcer and gastroesophageal reflux disease based on endoscopy. Methods This retrospective study used medical records of patients admitted with complaints of dyspepsia in Siloam General Hospital in Karawaci, Banten, Indonesia. Risk factors associated with peptic ulcer and gastroesophageal reflux disease such as epidemiological and clinical data collected were gender, age, symptoms, and results of endoscopy. Association between risk factors and peptic ulcer or gastroesophageal reflux disease were analyzed using Chi-Square Test and Fisher Test(bivariate analysis) and Logistic Regression (multivariate analysis). Results A total of 199 patients with dyspepsia symptoms were admitted on the period of 2017–2018, which 51 patients undergoing upper gastrointestinal endoscopy. The dyspepsia symptoms were the complaints the patients reported, including epigastric pain, throbbing pain, fullness, bloating, tenderness, mouth bitterness, heartburn, abdominal pain, vomit and decreased appetite. There were 33 patients with upper gastrointestinal endoscopy findings in accordance with peptic ulcer and gastroesophageal reflux disease. Bivariate analysis showed risk factors associated with peptic ulcer disease were epigastric pain (OR=1.778, 95% CI 0.889 - 3.555, p= 0.135), bloating (OR=0.419, 95% CI 0.277 - 0.635, p=0.199), and abdominal pain (OR=2.560, 95% CI 0.774- 8.809, p=0.064). Multivariate analysis showed a risk factor associated with peptic ulcer disease was abdominal pain (OR=5.333, 95% CI 0.885- 32.156, p=0.068). Conclusions Abdominal pain was the only risk factor associated with peptic ulcer disease and it was not statistically significant. There were overlapping dyspepsia symptoms among patients with peptic ulcer or gastroesophageal reflux disease in Karawaci, Banten, Indonesia.

Introduction. Spontaneous cholecystoduodenal fistula is a rare complication of the gallbladder calculosis. Bowel obstruction is the complication in less than 1% of these patients. The pathognomonic triad (Rigler triad) of pneumobilia, small-bowel distention, and ectopic gallstones is typical for gallstone ileus. In only 1?3% of the patients with bowel obstruction by ectopic gallstone the localization of obstruction is in the duodenum, and it is called Bouveret syndrome. The rarest complication is a floating non-obstructing gallstone trapped in the stomach. Outline of cases. We present three elderly female patients with persistent abdominal pain and known gallbladder calculosis in the patients? histories. Plain radiography of the thorax and abdomen and ultrasound were performed as the first choice and contrast-enhanced computer tomography (CT) was done subsequently. In the first patient, CT and magnetic resonance imaging (MRI) showed signs of pneumobilia, cholecystoduodenal fistula, and the presence of the gallstone in the stomach. The iodine contrast X-ray swallow test revealed a cholecysto-duodenal bulb fistula and floating calculus in the stomach, confirmed by endoscopy. In the second patient with persistent abdominal pain, CT and barium swallow test showed signs of pneumobilia, cholecystoduodenal fistula, and two ectopic gallstones obstructing duodenum ? Bouveret syndrome. The third case showed signs of the Rigler triad ? typical signs of gallstone ileus. Conclusion. Spontaneous cholecystoduodenal fistula is a rare condition with possible complications such as Bouveret syndrome, gallstone ileus and floating, non-obstructive gallstones in the stomach, as the rarest possible complication. CT, MRI with magnetic resonance cholangiopancreatography, as well as the contrast X-ray swallow test can be very helpful in the detection of the bilio-enteric fistula and ectopic gallstones.

Gallstone disease affects up to 20% of adults, but rare complications include Bouveret's syndrome, occurring in approximately 0.05% of patients with gallstones, and Mirizzi syndrome, with Type Va involving concurrent biliary and enteric fistulae. We report the case of a 64-year-old man with concurrent Bouveret's syndrome and Csendes Type Va Mirizzi syndrome associated with a cholecystoduodenal fistula. An initial laparoscopic cholecystectomy was abandoned due to concern for malignancy. During the same admission, the patient developed gastric outlet obstruction, and imaging confirmed Bouveret's syndrome caused by a large ectopic gallstone. This was managed with robotic-assisted gastrotomy and stone extraction as a damage-control procedure, with definitive biliary surgery deferred because of severe inflammation and unclear anatomy. Subsequent imaging demonstrated a residual Hartmann's pouch stone with Type Va Mirizzi syndrome and a persistent cholecystoduodenal fistula. The patient underwent a robotic subtotal cholecystectomy with intraoperative indocyanine green assessment and endoscopic evaluation. His postoperative course was complicated by peritonitis, bilious and enteric leakage, and intra-abdominal collections, requiring laparoscopic washout, radiological drainage, total parenteral nutrition, and endoscopic retrograde cholangiopancreatography with placement of a covered metal stent for a cystic duct stump leak. The patient recovered with multidisciplinary management and remained well at follow-up. This case illustrates the complexity of managing dual fistula-related gallstone disease and highlights the importance of staged decision-making, detailed imaging, and combined surgical and endoscopic approaches.

Bouveret's syndrome is defined as gastric outlet obstruction secondary to an impacted gallstone in the duodenum via a cholecystoduodenal or cholecystogastric fistula. Common radiological findings include pneumobilia, calcified right upper...

Bouveret syndrome is defined as gastric outlet obstruction secondary to the impaction of a large gallstone in the proximal gastrointestinal tract. The obstruction occurs as result of a bilio-enteric or bilio-gastric fistula. This clinical entity is a rare variant of the more commonly recognized gallstone ileus, which tends to cause small bowel obstruction of the terminal ileum. The typical presentation of Bouveret syndrome consists of nausea, vomiting and abdominal pain secondary to obstruction. Diagnosis often requires radiographic imaging with computed tomography, which typically shows pneumobilia or a cholecystoduodenal fistula. Herein is a series consisting of three cases of Bouveret syndrome involving a bilioenteric, cholecystoduodenal, and choledochoduodenal fistula, respectfully, all of which required operative management. A discussion of the current literature regarding management of this rare syndrome follows.

Introduction: Cholelithiasis is a common problem in the United States. In rare instances a cholecystoduodenal fistula may form. A large gallstone may pass through this fistula and move into the duodenum. These patients may present with gastric outlet obstruction (Bouveret's Syndrome). Case Report: A 72-year old woman with a history of coronary artery disease and hypertension presents with acute onset of bilious vomiting and abdominal pain. She denied any prior gastrointestinal symptoms or weight loss. A CBC revealed a white blood cell count of 12,100, hemoglobin of 13.7, hematocrit of 42.9, and a platelet count of 434,000. Total bilirubin was 0.4 and alkaline phosphatase of 202. An ultrasound of the gallbladder showed cholelithiasis without common bile duct dilatation or evidence of cholecystitis. An abdominal x-ray was nonspecific. An esophagogastroduodenoscopy revealed a large obstructing stone composed of both black and brown pigment in the second part of the duodenum. A lithotriptor cracked 25–30% of the 8×4 cm stone however; the entire stone could not be obliterated. The patient was taken to surgery later in the day. She had an open cholecystectomy and repair of a cholecystoduodenal fistula. The pathology showed gallbladder adenocarcinoma, invasive into the submucosa. Discussion: Bouveret's syndrome is a rare occurrence in patients with cholelithiasis. It occurs most commonly in women (65%) with a median age of 68 years. A specific etiology has not been discovered. The diagnosis is made by endoscopy (60%), upper GI series (45%) or x-ray (23%). Mortality has improved from 33% in 1968 to 12% in recent years. The pathogenesis of Bouveret's syndrome is formation of a cholecystoduodenal fistula secondary to inflammation of the gallbladder wall. The inflammation may be due to a number of causes including cholecystitis or possibly adenocarcinoma as in this case. Conclusion: Bouveret's syndrome may be suspected in a patient with known gallstone disease who presents with recent emesis. However, most cases of gallstone obstruction occur in the ileus. Radiologic or endoscopic workup may be necessary to confirm the diagnosis. Therapy includes multiple types of intervention, ranging from endoscopic laser or lithotripor ablation to surgery.

A 92-year-old female patient presented with prolonged nausea, vomiting, intractable abdominal pain, and loss of appetite. She had a history of gallstones and was recently given antibiotics for suspected cholecystitis. On presentation, she was afebrile without tenderness to palpation, rebound, or guarding. A computed tomography scan with oral and intravenous contrast revealed pneumobilia, periduodenal inflammation, a cholecystoduodenal fistula, and a 7-cm gallstone in the duodenal lumen (Fig. 1). On endoscopy, a large gallstone was found immediately distal to the pylorus in the duodenal bulb causing complete gastric outlet obstruction (Fig. 2). Due to her advanced age and comorbid conditions, a decision was made to treat this condition endoscopically. A total of four consecutive esophagogastroduodenoscopies were performed. Electrohydraulic lithotripsy (EHL) was used to fragment the stone, and fragments were removed using a Roth Net (Fig. 3). Localized moderate inflammation, erythema, and erosions were discovered in the distal duodenal bulb and proximal second portion of the duodenum. Successful fragmentation and removal of the impacted gallstone resolved the patient's gastric outlet obstruction, and the cholecystoduodenal fistula closed spontaneously. She remains well 12 months after endoscopic treatment. Bouveret's syndrome is a rare form of gastric outlet obstruction. Bilioenteric fistulas are formed due to chronic inflammation within the bile system allowing for penetration of gallstones from the gallbladder into the duodenum where they become lodged. Bourveret's syndrome accounts for nearly 2–3% of all gallstone related obstructions, occurring more commonly in elderly women with gallstones > 2.5 cm. Common presenting symptoms include nausea, vomiting, and abdominal pain; therefore, clinicians must have a high level of suspicion for the diagnosis in patients with a history of gallstones and symptoms of gastric outlet obstruction. Bouveret's syndrome has a morbidity and mortality rate of 30% often complicated by late diagnosis, misdiagnosis, and comorbidities. Few cases have reported the use of EHL in Bouveret's syndrome, with most showing success in fragmenting stones ≤3 cm. In this case, EHL has been proven successful and safe in the treatment of an elderly patient with a large gallstone stone, allowing for complete removal of the gastric outlet obstruction.

INTRODUCTION: Bouveret syndrome is an extremely rare and serious form of gallstone ileus with an incidence of 1-3% and a surgical mortality rate approaching 15-33 percent. Treatment often involves a combination of endoscopic and surgical interventions. We present a case of gastric outlet obstruction and duodenal ulceration caused by 3 impacted gallstones, treated ultimately with surgery. CASE DESCRIPTION/METHODS: A 57-year-old male with no known medical conditions was admitted to the intensive care unit with a one-week history of epigastric pain, nausea, and dark emesis. He was tachycardic and hypotensive on arrival. On exam, the patient was diaphoretic with dark-bloody return from the nasogastric tube. Hemoglobin was 5.6 g/dL (ref: 14.0-16.8 g/dL) with a leukocytosis of 17.69 K/uL (ref: 4.0-10.8 K/uL). Liver enzymes were unremarkable. Given concerns for an upper gastrointestinal bleed, patient underwent an esophagogastroduodenoscopy showing a 3-cm non-bleeding ulcer in the duodenal bulb, a cholecystoduodenal fistula, and a large impacted gallstone in the first portion of the duodenum distal to the fistula (Figure 1). Subsequent contrast-enhanced computed tomography demonstrated significant pneumobilia and a perforated duodenal ulcer (Figure 2). Removal of the obstructing gallstone was unsuccessful despite using a Raptor grasping device, Roth net retriever, and snare. Patient subsequently underwent exploratory laparotomy with cholecystectomy, pyloric exclusion, Roux-en-Y gastrojejunostomy, and duodenal enterorrhaphy with Graham patch (Figure 3). He tolerated the procedure well and was discharged to a rehabilitation facility. DISCUSSION: Bouveret Syndrome is a rare form of gallstone ileus characterized by gastric outlet obstruction secondary to gallstone impaction within the duodenum or pylorus through a cholecystoduodenal or choledochoduodenal fistula. Prompt imaging is warranted and in patients with gallstone ileus, may reveal pneumobilia, bowel obstruction, and ectopic gallstone, also known as Rigler's triad. Enterolithotomy, gastrostomy with cholecystectomy, and fistula repair are considered the mainstay of management, but prompt gastroenterological evaluation is warranted to evaluate the possibility of mechanical extraction or stone fragmentation.

Introduction: Bouveret syndrome is a rare condition characterized by the impaction of a gallstone in the stomach or duodenum via a fistulous tract resulting in gastric outlet obstruction. This condition generally requires surgery to remove the impacted stone. However, for patients who are unable to undergo surgery, laser lithotripsy can be an alternative therapy. Here, we present an interesting case of a patient with recurrent gallstone ileus successfully treated by endoscopic Holmium laser lithotripsy Case Description/Methods: A frail 79-year-old woman with chronic cholecystitis presented with right upper quadrant abdominal pain. Abdominal computed tomography (CT) scan demonstrated emphysematous calculous cholecystitis, a cholecystoduodenal fistula and a 30 mm gallstone lodged in the terminal ileum. She emergently underwent an ileocecal resection and partial right colectomy, confirming the diagnosis of gallstone ileus and a small bowel perforation. 10 days post-surgically, the patient again developed nausea, vomiting, and right upper quadrant pain. CT imaging re-demonstrated a 40 mm gallstone within the gallbladder fossa, Surgical options were limited due to a friable duodenum and inflammation of the cholecystoduodenal fistula. After a multidisciplinary discussion, endoscopic therapy was planned. Endoscopically, a large gallstone measuring about 40 mm was into the duodenal bulb eroding into the duodenum consistent with the known fistula. Holmium laser lithotripsy was used to fragment the stone. Due to the size of the gallstone, the procedure was performed in two sessions. During the first session, the stone was successfully fractured into smaller fragments. In the subsequent session, the remaining gallstone measuring about 28 mm was fragmented until the fistula tract was cleared. The larger gallstone fragments were removed using a roth net and a stone retrieval basket. Full resolution of the Bouveret syndrome was achieved. No immediate or delayed complications were noted. The patient is now doing well 3 months post-procedurally. (Figure) Discussion: Although surgery is often required for definitive therapy of Bouveret syndrome , endoscopic management remains a feasible option in select cases with appropriate expertise. Here, we present a case of successful endoscopic therapy utilizing Holmium laser lithotripsy in a high-risk patient for Bouveret syndrome. Although utilizing this technique is lengthy and requires advanced endoscopic expertise, provides a great benefit due to its minimal tissue injury and safety. Watch the video at https://tinyurl.com/ACGAbstractS362Figure 1.: A) Cholecystoduedenal fistula on CT scan, B) Holmium laser lithotripsy for Bouveret syndrome.

Purpose: Bouveret's syndrome is rare complication of cholelithiasis. It is characterized by gastric outlet obstruction caused by duodenal impaction of a large gallstone that passed into the duodenal bulb through a cholecystoduodenal fistula. It is critical to establish the diagnosis in order to perform an urgent therapeutic intervention. This is a case presentation of a patient with Bouveret's syndrome that was treated endoscopically with mechanical lithotripsy. A 93 year old female presented with abdominal pain, nausea, and vomiting for 1 week. Her past medical history was remarkable for coronary artery disease and hypertension. She was on Aspirin and Toprol®. On exam, she appeared confused, was febrile, and had a positive Murphy's sign. Laboratory data revealed leukocytosis, alkaline phosphatase of 152 U/l, alanine aminotransferase of 287 U/l, and total bilirubin of 3.3 mg/dl. Ultrasound of the abdomen showed dilated common bile duct and cholelithiasis. She was started on intravenous antibiotics. She underwent an urgent ERCP for suspected choledocholithiasis and cholangitis that revealed a 5 cm stone impacting the duodenal bulb. Gallbladder mucosa was fused with the duodenal bulb mucosa. The patient was a poor surgical candidate. Initial attempt to remove the stone endoscopically using a snare, rat tooth, and roth net failed. A percutaneous biliary drainage was placed by interventional radiology. An EGD was carried out on the subsequent day. Using a snare, the stone was broken into 2 pieces which were pulled back to the stomach. Then a mechanical lithotripter was used to break the stones into smaller pieces, all pieces were retrieved using a roth net. The patient recovered completely in 5 days and was discharged. The complication and mortality rates of surgical treatment can be substantial in patients with Bouveret's syndrome who are poor surgical candidates. In these patients endoscopic modalities can be carried out. This case illustrates a successful endoscopic treatment of Bouveret's syndrome using a combination of mechanical lithotripsy, a snare, and roth net. Mechanical lithotripsy is a safe approach and carries no additional significant risks.

After completing this article, readers should be able to: Recurrent abdominal pain (RAP) is a frequent and troublesome complaint in childhood and adolescence, and the search for a cause and a credible approach to management can be taxing for both family and physician. The term “recurrent abdominal pain” was coined by the British pediatrician John Apley, who first published on the subject in 1958. His definition included at least three attacks of pain occurring over a period of 3 months that were severe enough to affect activities and for which no organic cause was identified. In practice, the definition may include any child or adolescent who has RAP for which the family seeks medical attention and explanation, even if the duration of the pain does not adhere strictly to the Apley definition. The definition explicitly excludes the many causes of acute abdominal pain, which lie outside the scope of this review.There is wide variation in the threshold of severity and frequency that must be crossed before a family will seek medical attention for a child who has RAP. Inevitably, parents want a clear explanation and reassurance that no sinister causes lurk undetected, and the clinician wants to oblige but often lacks the conviction that organic causes have been excluded. The most difficult challenge for the clinician is to determine to what extent diagnostic studies should be employed before the label “recurrent abdominal pain” is applied. Whereas abdominal pain may be the chief manifestation of a large number of precisely defined illnesses, more than 90% of the time a “disease” will not be defined and the family will be left with a “functional” explanation. In spite of extensive study and a vast literature base, RAP remains an elusive symptom in search of an etiology. How to diagnose and manage this common pediatric problem constitutes the subject of this review.RAP has been reported to occur in 10% to 15% of children between the ages of 4 and 16 years. A community-based study of 500 adolescents (mean age, 15.5 y) revealed that 13% to 17% experienced weekly pain, which in 20% of cases was severe enough to affect activities. There clearly is an overlap between the “normal” population that may experience recurrent pain symptoms but not complain sufficiently to seek medical attention and others who have a seemingly similar degree and frequency of pain and do come for assessment. Many sociocultural, familial, and emotional factors determine a child’s response to pain, and these also will affect the likelihood of seeking medical attention to explain and treat the problem. Although Apley and others have reported RAP to be the most common pain syndrome of childhood, headaches and limb pains appear to have an equal prevalence.In a study of 1,000 school-age children, RAP affected males and females equally up to 9 years of age. After 9 years, the incidence in females increased such that between 9 and 12 years, the female-to-male ratio was 1.5:1. The overall incidence appears to peak at 10 to 12 years. RAP is rare among children younger than 5 years of age, and an organic cause must be considered even more carefully in this younger age group. The vast literature published on this subject reveals no evidence of changes in the incidence or clinical profile of this common pediatric pain syndrome; it seems to be here to stay.The origins of abdominal pain are complex and do not lend themselves to a single model of causation. Numerous organic disorders lead to abdominal pain; in most, the pathophysiology is related to inflammation (eg, Crohn disease) or distension or obstruction of a hollow viscus (eg, obstructive uropathy). Most studies indicate that fewer than 10% of children who present with RAP have an identifiable organic etiology.The exact mechanism of pain remains unclear in the majority of children in whom no organic cause can be identified. The most typical pattern of periumbilical pain so characteristic of RAP appears to be visceral in origin, probably originating in the small intestine or colon. To date, no pattern of consistent motility disturbance has been identified in any subgroup of patients experiencing nonorganic abdominal pain. Emotions, cognitive processes, and other central nervous system influences may modulate the perception of pain to produce an altered awareness of the discomfort from these visceral sensations. This “visceral hyperalgesia” describes a heightened awareness of sensations that might not be perceived or expressed as pain in other children.Models that try to relate psychological influences in a primary causal manner (emotional stress leads to RAP) are too simplistic. However, stress can cause recognized physiologic effects, such as increased cortisol levels, sympathetic tone, and tachycardia, so it is entirely plausible that it could exert physiologic effects on the gut through altered motility or some other as yet unidentified mechanism.Oft-repeated assumptions that children who have RAP are anxious, perfectionist, socially unskilled, and self-conscious have taken on an aura of validity that is unsupported by objective evidence. Several case-control studies have failed to demonstrate significant differences for a range of measures of psychological distress between groups of children who have “functional” RAP and those who have a demonstrable organic cause for their pain. Others contradict these studies, showing that those who have RAP have higher levels of anxiety and depression than do “well” children. Illness or pain clearly causes anxiety and distress, but this must be distinguished from invoking “stress” as a source of primary causation. There are no objective methods of measuring stress, and what seems to be a source of stress for one child (eg, birth of a sibling, upcoming athletic or music competition) may be of no apparent emotional consequence for another child of the same age. As in adults, some children seem to “buckle under stress” and become anxious and emotionally distressed; others facing the same challenge become invigorated and rise to new heights of effort and achievement.For some children, anxiety and emotional stress seem to manifest in a range of pain complaints, of which abdominal pain and headache are the two most common. Parents sometimes can date the onset of the pain to a specific time, such as the beginning of a new school year or a marriage breakup. Family dynamics and individual coping styles influence the way in which children express or even acknowledge their pain. Some families encourage their children to express pain in ways that unwittingly may reinforce the complaint.The tripartite classification proposed by Barr may be the most helpful method of categorizing children who present with RAP. This classification includes: 1) those who have organic disease, 2) those who have a clear psychogenic etiology such as depression or school phobia, and 3) the traditional “functional” group in which neither organic disease nor a clear psychogenic etiology is manifest.The majority of children who have RAP are considered to have a functional etiology. The problem of defining functional RAP is daunting. In its simplest form, the concept encompasses all causes that do not have an identifiable organic etiology. Most typically, the pain occurs in episodes that are periumbilical, self-limited, unrelated to meals or activities, and rarely if ever sufficient to awaken the child from sleep. The growth pattern and findings on the physical examination are normal. The degree of interference with normal activities and school attendance may seem out of proportion to the frequency and severity of the episodes as described. It has been observed wryly that “Organicity of pain is inversely proportional to the number of school absences.”Some children who have RAP manifest many of the characteristics associated with irritable bowel syndrome (IBS), as defined in adults. The criteria for making this diagnosis are: 1) abdominal pain relieved by defecation, 2) more frequent stools at the onset of the pain, 3) altered stool form (hard or loose or watery), 4) passage of mucus, and 5) associated bloating or abdominal distension. To define this syndrome requires a degree of detail regarding bowel function that the clinician will find difficult to elicit from children, who are notoriously reluctant to reveal or discuss their bowel habits. In adults, the division is made between those who have constipation-dominant and diarrhea-dominant symptoms. There is some evidence that altered intestinal motility, mediated by peptides excreted by both gut and brain, plays a role in the etiology of IBS. There are no laboratory markers; the diagnosis rests on the history. Although some clinicians include constipation under the diagnostic category of IBS, most recognize it as a separate diagnosis.Many factors lead to constipation in children, the foremost of which is dietary. Modern diets are replete with highly processed starches, and many children shun fruits, vegetables, and higher-fiber foods. An unwillingness by some children to take the time to evacuate their bowels completely, coupled in some cases with a reluctance to use school washrooms, can seriously compound this problem. Sometimes the role of constipation as a major contributing factor to abdominal pain will be clear, with the parent noting that the child goes days between bowel movements and that the stool is bulky and hard. Often the pediatrician faces the problem of ferreting out this diagnosis in the face of inadequate history; the parent is unaware of the child’s bowel pattern and the child is tight-lipped and unwilling to discuss the matter in any detail. Findings on abdominal and rectal examinations may not confirm this diagnostic suspicion; a plain abdominal radiograph may be needed.There may be a long latency between onset of symptoms and a confirmed diagnosis of inflammatory bowel disease (IBD). Although ulcerative colitis often presents with abdominal pain associated with hematochezia and tenesmus, the early symptoms of Crohn disease may be more insidious and nonspecific. Abdominal pain and diarrhea may be intermittent, and the clinician must be alert to the presence of lethargy, growth and pubertal delay, and extraintestinal manifestations such as oral, joint, and perirectal involvement. With the widespread availability of endoscopy, a diagnosis usually can be made promptly.The frequency with which incomplete absorption of lactose and other carbohydrates produces RAP in children is unclear, as are outcomes in several large and well-conducted studies. Initial enthusiasm for this diagnosis as a significant cause for RAP has waned. A wide range of racial/ethnic groups—Asian, Jewish, Mediterranean, and African-Americans—are predisposed to lactase deficiency, with incidences reported as high as 60% to 80%. Lactose ingestion will cause symptoms of bloating, loose stools, and cramping abdominal pain in those who are affected. It appears to be an uncommon cause of RAP in the absence of other gastrointestinal symptoms. The diagnosis is made most reliably by breath hydrogen testing. If this diagnostic tool is unavailable, it is reasonable to use lactase-treated milk products or a complete restriction of milk products for several weeks as a therapeutic trial. It is important to recognize that lactose intolerance results simply in carbohydrate maldigestion; it is not, per se, a cause of malnutrition or growth failure.The discovery of H pylori has changed the approach to diagnosis and treatment of peptic ulcer disease. Epidemiologic evidence indicates that this infection is more prevalent among those living in low socioeconomic circumstances, so infection rates are significantly higher in less developed nations. Even in developed countries, the prevalence of H pylori infection is approximately 40%. However, the great majority of affected individuals have no signs or symptoms; they have infection but no disease.The intense interest in H pylori has generated numerous tests and treatments that, unfortunately, are being used in excess of their established benefits and often counter to the best interests of the patient.Several lines of evidence indicate that H pylori infection alone rarely is the cause of abdominal pain in children unless peptic ulcer disease is present. A meta-analysis of more than 40 published reports shows strong evidence for an association between H pylori gastritis and duodenal ulcer disease in children, but weak or no evidence for an association between H pylori infection and RAP. Serologic studies have shown that antibodies to H pylori occur with similar prevalence among children who do and do not have RAP. In a large multicenter study from Germany, symptom assessment could not distinguish between children who had H pylori gastritis and those who had “functional” RAP. Symptoms improved or resolved in 87% of children in whom H pylori was eradicated successfully, but also in 93% of those in whom eradication failed and in 80% of those who had “functional” RAP. H pylori-associated peptic ulcer disease should be suspected when abdominal pain is primarily epigastric; when it awakens the child from sleep; and when it is associated with anorexia, nausea, recurrent vomiting, anemia, or gastrointestinal bleeding. Although abdominal pain is common in children, peptic ulcer disease is very uncommon; therefore, testing for H pylori should not be part of the preliminary evaluation of a child who has RAP.Given the important distinction between H pylori infection and disease, engaging in a fishing expedition for evidence of H pylori infection is not an appropriate strategy for investigating RAP. Antibodies in serum or saliva may remain elevated for years after infection has resolved, making their mere presence unhelpful in initial diagnosis. The urea breath test is reliable for detecting the presence of H pylori infection, but many causes of esophagitis, gastritis, and peptic ulcer disease present with similar symptoms. Therefore, when the weight of symptoms suggests the presence of ulcer disease, endoscopy with biopsies is the optimal approach for confirming the diagnosis and guiding treatment. Fecal antigen tests look promising, but their role in children has not yet been defined.H pylori causes approximately 70% of primary peptic ulcer disease in children, but about 30% is idiopathic. In addition, secondary ulcer disease may be associated with nonsteroidal anti-inflammatory drug ingestion, Crohn gastritis, and other forms of erosive gastritis.Dyspepsia is a symptom complex of epigastric pain, bloating, and discomfort that may occur with or without demonstrable acid reflux. “Nonulcer dyspepsia” is designated when these symptoms are accompanied by negative endocopic and biopsy findings.The association between migraine and abdominal pain remains mysterious, and many clinicians view the existence of a discreet entity of “abdominal migraine” as dubious. Because migraine is a common problem in both pediatric and adult medicine, with a prevalence reported to be as high as 5%, some children who have headache due to migraine also will experience RAP. “Abdominal migraine” usually is recognized when episodes of paroxysmal abdominal pain occur in association with nausea and vomiting, with complete recovery between episodes and sometimes with associated headache. A strong family history of migraine lends credibility to the diagnosis. Most pediatricians only accept abdominal migraine as an explanation for RAP when the patient has headaches that are conclusively migraine.The contribution of parasitic infestation to RAP is elusive. Infection with Yersinia enterocolitica can cause enteritis that mimics IBD, albeit usually associated with diarrhea. It is well-recognized that infestation with Giardia can cause diarrhea associated with abdominal cramps and pain, but diarrhea usually is the predominant complaint. The possible role of Dientamoeba fragilis and Blastocystis hominis in causing RAP in the absence of diarrhea has been raised in a small number of studies, but their role remains dubious. With the present state of knowledge, a search for an infectious etiology for RAP is not usually warranted in the absence of diarrhea.Many gynecologic conditions can present with RAP and must be given careful consideration, especially in postpubertal females. Early menarche, endometriosis, pelvic inflammatory disease, and ovarian cyst are important diagnostic possibilities. Many of these causes can be elucidated by ultrasonographic examination.Abuse always requires careful consideration in children who have RAP, and sensitive history taking is required to elucidate its possible role.It is heartening to reassure clinicians in the 21st century that the most powerful diagnostic tools they bring to the problem of RAP in childhood are a thorough history and physical examination. The proliferation of diagnostic technology threatens to obscure the foremost need that patients and their families be heard, not investigated. A correct diagnosis usually can be suspected following a good history and physical examination. In addition to their diagnostic roles, a complete history and physical examination will help to convince parents that their concerns are taken seriously.A successful history places the patient and family at ease and allows them to express their concerns unhurriedly. As children advance in age, they are included in the history taking, and part of the interview of an adolescent should take place separately from the parents. It may be wise to conduct the initial interview with the parents alone; this should be discussed with the parents at the outset to reach a mutually agreeable decision. Successful interviewing involves active, empathetic listening followed by explanations given in language and terms that the family understands. The most satisfied parents are those who feel that they have been heard, and the physician who listens well earns a high degree of confidence and credibility.The history should explore the location, nature, and frequency of the pain, along with associated symptoms. It should be acknowledged that the child’s description of the nature of the pain (eg, sharp, dull) is of limited importance in making a diagnosis because children often are unclear as to the meaning of these descriptors. The relationship of the pain to school and social/family stressors is important to elicit. 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Bouveret's syndrome is a rare form of bowel obstruction caused by the impaction of a large gallstone through a cholecystoduodenal fistula, leading to gastric outlet obstruction. This article aims to highlight the clinical presentation and management of this syndrome, given its low incidence and high mortality rate of 12% to 30%. We present the case of an 83-year-old patient with a history of diabetes and hypertension who presented with abdominal pain, distension, and vomiting. Computed tomography revealed duodenal obstruction due to a large gallstone. A diagnostic laparotomy was performed, allowing for the removal of the stone through enterotomy. The patient had an uncomplicated recovery and was discharged on the seventh day of hospitalization. Early diagnosis and effective management are crucial, with endoscopy as the preferred initial treatment, although surgery may be necessary if endoscopy fails. Tailoring the treatment to the patient's condition is essential to improving outcomes and reducing associated mortality.