Bouveret Syndrome: When There Are No Options
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Notice bibliographique
Résumé
Division of Gastroenterology, McMaster University, Hamilton, Ontario Corrrespondence: Dr Harith Baharith, McMaster University, Division of Gastroenterology, 1280 Main Street West, Hamilton, Ontario L8N 3Z5. Telephone 289-700-2244, fax 905-648-1906, e-mail harith.baharith@medportal.ca Received for publication November 10, 2014. Accepted December 5, 2014 CASE PRESENTATION An 85-year-old female nursing home resident presented with a medical history of dementia, stroke, hypertension, gastroesophageal reflux disease and cholethiasis. The patient was referred because of four episodes of coffee-ground emesis and symptoms of right upper quadrant abdominal pain, with no issues with bowel movements. There was limited other information available due to the underlying history of dementia. The patient’s vital signs were stable. Physical examination revealed normal cardiorespiratory parameters. The abdominal examination revealed a tender right upper quadrant, with no palpable mass and the presence of bowel sounds. Laboratory investigations revealed a white blood cell count of 18.4×109/L (normal 4.0×109/L to 11.0×109/L), alkaline phosphatase level of 131 U/L (normal 40 U/L to 120 U/L) and gamma-glutamyl transferase level of 116 U/L (normal <37 U/L). The remaining laboratory investigations were unremarkable. An abdominal x-ray revealed a large, rounded, lamellated calcification in the epigastric region measuring approximately 4.5 cm × 3.3 cm (Figure 1). The patient underwent a computed tomography scan, which revealed gastric outlet obstruction secondary to an impacted gallstone within the duodenum, a cholecystoduodenal fistula and a collpased gallbladder, with thickening of the gallbladder wall and air within the gallbladder (Figure 2). The patient was initially managed with intravenous fluids, nasogastric tube, antiemetics and antibiotics. An urgent endoscopy was arranged by gastroenterology, revealing a stone impacted in the duodenal cap (Figure 3). Attempts to push or bypass the stone were unsuccessful, followed by attempts at retrieval with snare, basket, pronged grasper and Roth net, all of which were also unsuccessful. Additional attempts by another gastroenterologist and surgeon using endoscopic therapy to disimpact the stone were unsuccessful. The surgeon then suggested operative management for the patient; however, due to the patient’s deteriorating medical condition, the palliative team involved in her care and the family elected to proceed with palliation instead of surgery. After a three-week hospital stay, the patient was transferred to a hospice care facility where she died within one week.
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Prédiction distillée sur la base complète
Imitation des enseignantsNi prévalence calibrée, ni vérité terrain. Validation humaine à venir. Apprise à partir de 10 348 étiquettes directes de Codex et de 10 348 étiquettes directes de Gemma. Le mode candidate est l'union des têtes enseignantes seuillées; le consensus est leur intersection. Ces sorties portent le statut machine_predicted_unvalidated et ne sont ni des étiquettes humaines ni des étiquettes directes de modèles de pointe.
Scores Codex et Gemma par catégorie
| Catégorie | Codex | Gemma |
|---|---|---|
| Métarecherche | 0,000 | 0,000 |
| Méta-épidémiologie (sens strict) | 0,000 | 0,000 |
| Méta-épidémiologie (sens large) | 0,000 | 0,000 |
| Bibliométrie | 0,000 | 0,000 |
| Études des sciences et des technologies | 0,000 | 0,000 |
| Communication savante | 0,000 | 0,000 |
| Science ouverte | 0,000 | 0,000 |
| Intégrité de la recherche | 0,000 | 0,000 |
| Charge utile insuffisante (le modèle a refusé de juger) | 0,000 | 0,000 |
Scores machine (provisoires)
Les deux têtes enseignantes du modèle étudiant, lues sur ce travail. Un score ordonne la base pour la relecture; il n'affirme jamais une catégorie, et le statut de validation accompagne chaque rangée tel quel.
Scores de référence d'un modèle non mature (critères de maturité non atteints, 7 itérations). Un score ordonne; il n'affirme jamais une catégorie.
score_only:v0-immature-baseline · tel quel depuis la passe de notation : score_only signifie que le nombre peut ordonner les travaux, et qu'aucune étiquette de catégorie n'en découle