Bouveret Syndrome Presenting as Duodenal Bulb Stenosis and Gastric Outlet Obstruction: A Case Report

Laparoscopy-assisted endoscopic ultrasound-guided gastroenterostomy for the treatment of gastric outlet obstruction.

EUS-guided gastroenterostomy (EUS-GE) is rapidly emerging as a pivotal procedure in the management of gastric outlet obstruction due to its advantages over historical comparators such as surgical gastroenterostomy and endoscopic placement of gastroduodenal stents. The ability to create a stable surgical-range connection between 2 lumens, distant from the tumor, with the minimally invasive nature of an endoscopic procedure, offers high clinical efficacy, acceptable safety, and low recurrence rates. However, widespread adoption is impeded by the steep learning curve and lack of standardized methodologies. Like other interventional EUS procedures, EUS-GE utilizes lumen apposing metal stents. Unlike drainage procedures, the target in EUS-GE is a mobile structure with a virtual resting caliber that needs to be distended to create the connection, making misdeployment a significant drawback. This comprehensive illustrated technical review dissects the general and specific technical principles of EUS-GE covering the equipment, scene, settings, and endoscopic signs of correct and incorrect placement. It provides a deeper insight into the wireless simplified EUS-GE technique, the EUS-guided double-balloon-occluded gastrojejunostomy bypass, and the direct technique. Through pragmatic tips, expert advice, and elucidative step-by-step videos, a systematic roadmap for mastering this intricate procedure is presented. By addressing common challenges and providing troubleshooting strategies, this review aims to demystify EUS-GE, equipping practitioners with the tools to achieve reproducible and optimal outcomes.

Comparative Efficacy and Safety of Treatments for Malignant Gastric Outlet Obstruction: A Systematic Review and Network Meta-analysis.

Gastric outlet obstruction (GOO) is a clinical syndrome caused by mechanical impediment to gastric emptying. Bezoars account for < 0.4% of all GOO cases. Of these, duodenal bezoars—particularly those obstructing the narrow duodenal bulb—are exceptionally rare. Duodenal persimmon phytobezoar-induced gastric outlet obstruction (GOO) is particularly distinctive in elderly patients, with only a handful of relevant case reports documented in the literature. We present the case of successful endoscopic fragmentation in an 88-year-old female with GOO caused by a persimmon bezoar located in the duodenal bulb. Abdominal CT and upper endoscopy showed a giant bezoar nearly completely obstructing the duodenal lumen. After 3 days of failed chemical dissolution with sodium bicarbonate solution and Coca-Cola, she underwent two endoscopic fragmentations using simple and readily-available endoscopic instruments, such as rat-tooth forceps, snares, and baskets. More than ten persimmon seeds were extracted during the procedure. Upper endoscopy was repeated and revealed that the bezoar had disappeared, with two necrotic pressure ulcers noted in the duodenal bulb. The patient recovered well and was discharged 4 days following the second endoscopic fragmentation. The patient remained asymptomatic during 3 months of follow-up. Phytobezoars are rarely found in the duodenum, as in the case of this patient. This case highlights the feasibility and efficacy of endoscopic therapy for duodenal bezoar-induced GOO, especially in elderly patients. Furthermore, the use of simple, readily-available endoscopic instruments (rat-tooth forceps, snares, and baskets) makes this approach particularly suitable for use in resource-limited settings.

Introduction and importance: Gastric lipomas are uncommon; diffuse gastric lipomatosis is rarer, and pyloric involvement may cause bleeding or intermittent gastric outlet obstruction. We report a pylorus-spanning lipomatosis treated definitively by laparoscopic distal gastrectomy. Presentation of case: A 75-year-old man presented with melaena and post-prandial epigastric discomfort. Endoscopy revealed a broad-based submucosal mass at the pyloric canal intermittently prolapsing into the duodenal bulb with a small healing ulcer. computed tomography (CT) showed an 8.1 × 2.7 × 3.8 cm multiseptated fat-density mass traversing the pylorus with luminal narrowing. Positron emission tomography-CT demonstrated no abnormal hypermetabolism. Because of recurrent symptoms and trans-pyloric extension, laparoscopic distal gastrectomy with Billroth II reconstruction was performed. Histopathology confirmed diffuse lipomatosis of mature adipocytes without atypia. Recovery was uneventful; 1-month and 2-year imaging showed durable patency without recurrence. Clinical discussion: Gastric lipomatosis is rare. Treatment options include endoscopic submucosal dissection and laparoscopic–endoscopic cooperative approaches such as laparoscopic–endoscopic cooperative surgery, non-exposure endoscopic–laparoscopic cooperative surgery (NEWS), and CLEAN-NET (combination of laparoscopic and endoscopic approaches to neoplasia with non-exposure technique). In pylorus-spanning diffuse lipomatosis, however, distal gastrectomy remains among the most reliable strategies for definitive symptom control. Conclusion: In symptomatic, pylorus-spanning gastric lipomatosis, laparoscopic distal gastrectomy offered dependable, durable relief of obstruction.

Abstract Background Gastric outlet obstruction (GOO) is a rare complication of Crohn’s disease (CD), resulting from stricturing gastroduodenal disease. Management is complex, with medical, endoscopic, and surgical options reported. Aims To synthesize evidence on the management of CD-associated GOO and compare treatment success rates. Methods Following PRISMA guidelines, MEDLINE, PubMed, and Embase were searched for studies describing GOO secondary to CD. Case reports, case series, and observational studies reporting treatment outcomes were included. Non-English studies were excluded. Results Of 282 studies screened, 57 studies comprising 230 patients were included. We identified 295 treatment trials for CD–related GOO. Success was defined as complete resolution of symptoms and absence of recurrence at the end of the follow-up period. Outcomes for treatment regimens are summarized in Table 1 and Figure 1. Surgery achieved the highest success (94%, n = 80 for surgery alone; 100%, n = 7 for surgery plus medical therapy), and was offered as first-line therapy in 41% of cases. Endoscopic balloon dilation (EBD) achieved 65% success alone (n = 133) and 75% when combined with medical therapy (n = 20). Medical therapy alone with disease-modifying drugs was less effective (50%, n = 26 for single agents; 44%, n = 16 for combination regimens), while supportive therapy alone (n = 13) did not achieve any resolution. Considering each modality independently of the regimen, success rates were highest for surgery (94%), followed by TNFα inhibitor biologics (68%) and EBD (66%). EBD alone was the most common first-line approach resulting in complete resolution of GOO. Conclusions Surgery provides the most durable resolution of CD-related GOO. However, EBD is frequently effective and less invasive, making it a reasonable initial option. Medical therapy alone is less effective, though regimens including TNFα inhibitor biologics may have a role. This scoping review is the first to synthesize treatment strategies for this uncommon manifestation of CD. Funding Agencies None

Abstract Background Gastric outlet obstruction (GOO) presents with nausea, vomiting, weight loss, early satiety, and abdominal distension due to impaired gastric emptying. While most gastric polyps are asymptomatic, larger polyps may prolapse through the pylorus and cause GOO in a “ball-valve” manner and may undergo malignant transformation. Current evidence is limited to case reports, case series, and reviews. This systematic review synthesizes primary data on presentation, diagnosis, management, and outcomes of GOO secondary to gastric polyps. Aims To summarize the evidence on symptomatology, diagnostic approaches, and treatment of gastric polyp–related GOO. Methods A PRISMA-based systematic review of MEDLINE, Embase, Scopus, and Web of Science was conducted. Descriptive statistics were used for demographics and treatment outcomes. Results Of 408 articles, 56 (52 case reports, 4 case series) published up to April 2025 were included. Median age at presentation was 47 years (range 2 days–89 years) with female predominance. Common symptoms included epigastric/abdominal pain, nausea, and vomiting. Polyps were usually in the antrum with a median size of 4 cm. Upper endoscopy was diagnostic in 91.8%, often revealing a pedunculated polyp prolapsing into the duodenum. CT was used in 34% as adjunct imaging. Endoscopic resection was performed in 24/61 cases (39.3%) and was curative in all. Surgical management was required in 27/61 (44.3%), especially for large or sessile lesions. Symptom resolution occurred in 58/61 cases (95%). Conclusions In patients with weight loss, vomiting, and anemia, malignancy should first be suspected due to overlapping symptoms. GOO is a clinical diagnosis, and benign polypoidal causes should be considered once malignancy is rule out. Given malignant potential, polypectomy is first-line, with endoscopic or surgical approach based on polyp size and extent. Both methods show excellent outcomes and no procedure-related mortality. Hereditary polyposis syndromes should be considered in patients with personal or family history. Management should be individualized based on presentation, comorbidities, histology, and extent of polyposis. Further long-term studies are needed to assess recurrence after polypectomy. Funding Agencies None

Abstract Background Endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ) using a lumen-apposing metal stent (LAMS) is a minimally invasive therapy for gastric outlet obstruction (GOO), offering durable symptom relief and faster recovery than surgical or enteral approaches. This study describes successful application of this novel technique in a Canadian setting. Aims To evaluate procedural and clinical outcomes of EUS-GJ at a Canadian tertiary centre. Methods A retrospective single-centre review was conducted at Vancouver General Hospital (Aug 2023–May 2025). All consecutive patients undergoing planned EUS-GJ for malignant or benign GOO were included. Demographic, procedural, and clinical data were collected. Technical success was defined as successful LAMS deployment, and clinical success as achieving a Gastric Outlet Obstruction Scoring System (GOOSS) of >1without recurrent obstruction within 30 days. Results Twenty-four patients underwent attempted EUS-GJ (median age 66.5 years [IQR 61.2–73.5]; 46% female). Twenty-two (92%) had malignant obstruction, most commonly pancreatic adenocarcinoma (45%) and two benign indications including afferent limb syndrome and pyloric stenosis. Median ASA class was 3. The obstruction was most commonly duodenal (75%), followed by antral or pyloric (17%). Nearly half had prior enteral stenting or dilation, highlighting EUS-GJ as salvage therapy in refractory obstruction. All procedures were performed under general anesthesia using electrocautery-enhanced LAMS (15–20mm x10mm). Transgastric access was used in 22 (92%) and transbulbar in 2 (8%). Technical success was achieved in 23/24 (95.8%). One procedure was aborted due to interposed ascites with successful deployment of a duodenal stent instead. Clinical success was achieved in 23/24 (95.8%). Median GOOSS improved from 0 [IQR 0–0.8] to 3 [IQR 2.3–3.0]. Median hospital stay was 5 days (IQR 1.8–10.2). Two adverse events occurred: one aspiration requiring brief ICU stay, and one contained perforation adjacent to a pre-existing gastric stent managed non-operatively. No LAMS-related perforations, misdeployments, or surgical rescues occurred. Several patients resumed systemic therapy within weeks, reflecting rapid recovery and preserved performance status. Conclusions EUS-GJ with LAMS achieved high technical and clinical success with minimal morbidity and short hospitalization in a medically complex Canadian cohort. These findings illustrate safe and effective integration of advanced therapeutic EUS in real-world tertiary practice and support EUS-GJ as a durable, minimally invasive option for palliation of GOO. Funding Agencies None

Abstract Background The clinical trajectory of patients with peripancreatic collections is heterogenous and long-term outcomes following endoscopic drainage remain poorly characterized. Aims This study aims to evaluate long-term outcomes in patients with PPFC who underwent different drainage modalities and determine independent predictors of time to clinical improvement. Methods Consecutive adult (age ≥ 18 years) patients with history of acute pancreatitis and radiologically confirmed PPFC who underwent endoscopic drainage were included. PPFC were categorized as simple (localized collections) or complex (extending into the paracolic space). The primary outcome was time to clinical improvement, defined as resolution of infection, biliary or gastric outlet obstruction, or pain. Secondary outcomes included predictors of clinical improvement and overall PPFC resolution. Results A total of 404 patients were included in this report. The mean age was 54.18 years (SD 15.3), 68.81% were male and 254 (62.9%) had complex collections. LAMS or BFMS placement was associated with a faster time to improvement (HR = 1.95, 95% CI: 1.32-2.90, p = 0.001), whereas complex collections (HR = 0.30, 95% CI: 0.21-0.44, p < 0.001) and prolonged hospitalization (HR = 0.99, 95% CI: 0.98-0.99, p < 0.001) were predictors of delayed clinical improvement. In comparison with patients with simple collections, those with complex collections had lower collection resolution rates (68.62% vs. 88.41%, p < 0.001) as well as higher rates of readmission (median of 3 [IQR: 0–5]) vs 3 [IQR: 0–3], p = 0.03), multiorgan failure (15.8% vs 1.3%, p < 0.001), and portal vein thrombosis (7.1% vs. 2.0%, p = 0.02). Conclusions Patients with complex collections, extending into the paracolic space, had prolonged recovery and increased intervention requirements. In these patients, metal stent (LAMS or BFMS) placement significantly accelerated clinical improvement. Further research is needed to refine management strategies for these high-risk patients. A317 Table 1: Results of Cox Proportional Hazards Regression Analysis for Time to Clinical Improvement Funding Agencies None

Acute severe gastric outlet obstruction in the setting of gastric adenocarcinoma

Background: Surgical gastrojejunostomy (S-GJ) is the standard treatment for gastric outlet obstruction (GOO), but is associated with significant morbidity, high cost, and prolonged recovery. Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) provides a minimally invasive alternative, however the anastomosis often closes after removal of the lumen-apposing metal stent (LAMS), limiting its role to palliation. We evaluated the feasibility of the double LAMS septotomy technique, to achieve durable gastroenterostomy without reliance on indwelling stents. Methods: This was a multicenter pilot-feasibility study, where consecutive adults with GOO, underwent EUS-GE with double LAMS septotomy between 2024 and 2025. Step-one involved placement of two adjacent LAMS to create parallel gastroenteric fistulas. Step-two, performed three months later, included stent removal with or without septotomy to consolidate the anastomosis. Technical success, clinical success, adverse events and sustained patency of the anastomosis after LAMS removal were assessed prospectively. Results: Six patients (Mean age 70.3 years, 50% benign GOO) underwent the procedure. Technical and clinical success rates were 100%. Four patients completed both steps, with sustained anastomotic patency, confirmed endoscopically or radiographically. Amongst these, spontaneous septum necrosis occurred in 2 patients (50%) and 2 patients (50%) required septotomy. Nutritional status improved (mean albumin +0.75 g/dl). There were no major adverse events. The patients had no recurrence of symptoms after a mean follow up 26.2 weeks and 17.8 weeks after step-one and step-two respectively. Conclusion: The Double LAMS septotomy technique is technically feasible, safe and achieves durable gastrojejunostomy. This strategy may broaden the therapeutic role of EUS-GE in benign disease.

BACKGROUND Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal neoplasms of the gastrointestinal tract. Their presentation varies from bleeding to perforation, but they rarely manifest as gastroduodenal intussusception or obstructive jaundice. We report a rare case of a gastric GIST that caused intussusception leading to gastric outlet obstruction with biliary obstruction and acute pancreatitis. CASE REPORT A 71-year-old woman presented with melena, vomiting, and generalized weakness. Evaluation revealed severe anemia and elevated liver and pancreatic enzymes. Imaging and endoscopy identified a large polypoid mass in the gastric antrum prolapsing into the duodenum. Magnetic resonance cholangiopancreatography showed a dilated common bile duct but no choledocholithiasis. She was advised to undergo surgery, during which a gastroduodenal intussusception compressing the ampulla was identified. The mass was excised via gastrotomy with wide margins. Postoperative recovery was uneventful. Histopathology confirmed a low-grade (G1) gastric GIST (pT3, CD117/Discovered On GIST-1 [DOG1]-positive, Ki-67 ~3%) with clear margins. CONCLUSIONS Gastroduodenal intussusception is a rare condition in adults. Fewer than 50 cases have been reported, and more than half were attributed to GISTs. Obstructive jaundice or pancreatitis due to external ampullary compression is uncommon. Imaging modalities such as computed tomography and magnetic resonance imaging are essential for diagnosis. Surgical excision remains the mainstay of management. This case highlights a rare, complex presentation of gastroduodenal intussusception with biliary obstruction due to a gastric GIST.

Peptic ulcer disease (PUD) is a common gastrointestinal disorder characterized by ulcerative lesions in the gastric and duodenal mucosa resulting from an imbalance between aggressive factors, such as gastric acid and pepsin, and protective mechanisms of the mucosal barrier. Despite a decline in its global incidence, PUD remains a significant public health concern due to its association with morbidity, hospitalizations, and potentially life-threatening complications. This study aims to describe the clinical presentation and diagnostic approaches of peptic ulcer disease, emphasizing their relevance to early detection and appropriate management. This literature review was based on the analysis of scientific publications addressing the clinical manifestations, etiological factors, and diagnostic strategies of PUD. The disease presents with variable symptoms, most commonly epigastric burning pain related to food intake, nausea, vomiting, and abdominal distension. Elderly patients may present atypically or remain asymptomatic, which can delay diagnosis. Alarm signs such as hematemesis, melena, unexplained weight loss, and anemia indicate the need for urgent investigation. Upper gastrointestinal endoscopy remains the gold standard for diagnosis, allowing direct visualization of lesions and biopsy for malignancy exclusion. Early recognition and appropriate diagnostic evaluation are essential to prevent complications such as bleeding, perforation, and gastric outlet obstruction, thereby improving patient outcomes and quality of life.

Background:Gastric outlet obstruction (GOO) caused by malignancy significantly impairs patient quality of life. Surgical gastrojejunostomy (SGJ), endoscopic stenting (ES), and endoscopic ultrasound-guided gastroenterostomy (EUS-GE) are the three main palliative treatments. However, the optimal approach remains unclear because of variations in study results and limited studies comparing treatment types.Objectives:To evaluate and compare the effectiveness and safety of EUS-GE, ES, and SGJ in the management of GOO.Design:Network meta-analysis.Data sources and methods:The PubMed, Cochrane Library, and Web of Science databases were systematically searched for full-length articles of randomized controlled trials and cohort studies in English comparing SGJ, ES, and EUS-GE in adult patients with malignant GOO. Studies with unbalanced baseline characteristics or technical variations within a single modality were excluded. The primary outcome was the reintervention rate for recurrent GOO. Secondary outcomes included clinical success and adverse event rates.Results:Fifty-four studies involving 6110 patients were analyzed (SGJ, n = 1974, ES, n = 3226, EUS-GE, n = 910). Compared with ES, both SGJ (odds ratio (OR): 0.32, 95% confidence interval (CI): 0.22–0.46) and EUS-GE (OR: 0.29, 95% CI: 0.17–0.51) significantly reduced the risk of reintervention. EUS-GE achieved a higher clinical success rate than ES (OR: 2.46, 95% CI: 1.50–4.04) and also lower adverse event rate than both SGJ (OR: 0.33, 95% CI: 0.19–0.56) and ES (OR: 0.61, 95% CI: 0.37–0.99). Heterogeneity was moderate across outcomes, with no major inconsistency or publication biases detected.Conclusion:Of the three treatments for GOO, EUS-GE demonstrated the most favorable profile in terms of efficacy, safety, and durability. SGJ remains a viable alternative, particularly in centers lacking expertise in advanced endoscopy. These findings may inform future clinical guidelines and support the broader adoption of EUS-GE in appropriate settings.

Noncommunicating gastric duplication cyst at the pylorus in a 5-year-old child: a case report

Background: Delayed gastric emptying (DGE) is the most common complication following palliative gastrojejunostomy (GJ) for gastric outlet obstruction. Whether roux-en-Y (RY) reconstruction offers a clinical edge over the loop configuration remains unclear. Materials and Methods: The prospective cohort study included 41 patients who received either RY ( n = 19) or loop ( n = 22) GJ. The main study endpoint consisted of composite DGE (ISGPS Grades A/B/C) within 30 days. The research used multivariable logistic regression to determine independent risk factors. Results: DGE occurred in 22% overall, significantly less with RY (5%) than loop (36%; P = 0.024). RY remained protective after adjustment (adjusted odds ratio: 0.10; P = 0.053), while malignancy and male sex increased risk. Length of stay and serious morbidity were similar across groups. Conclusions: RY-GJ may markedly reduce postoperative DGE without added morbidity. Despite promising findings, the small sample size and nonrandomized design warrant cautious interpretation. Further validation in randomized trials is needed before routine use.

EUS-guided versus surgical gastroenterostomy for the management of malignant gastric outlet obstruction: A systematic review and meta-analysis.

Mesenchymal proliferations involving the gastrointestinal tract are uncommon and often unexpected upon initial clinical presentation. Here, we are reporting a case of a 20-year-old male patient presenting to the hospital with abdominal pain and vomiting. Upon evaluation, the patient was initially discharged home on antacid therapy. The symptoms progressed in intensity, and a subsequent CT scan was remarkable for marked gastric expansion and a prepyloric mass. The macroscopic examination of the resected lesion revealed a 5.6 cm multilobular fibrotic mass involving the gastric wall. Microscopic analysis was notable for a spindle-cell lesion with admixed lymphoplasmacytic inflammation, patchy necrosis, and calcifications. The immunohistochemical workup was suggestive of a reactive nodular fibrous pseudotumor. This case is notable for several aspects, including the acute clinical presentation, intralesional calcifications, abundant IgG4-positive plasma cells, and lack of CD117 immunohistochemical expression. The peculiarities of the case and a review of the medical literature will be presented.

Balloon dilatation vs self-expandable metal stents placement for benign gastric outlet obstruction.