An incidental choledochoduodenal fistula discovered during gastroscopy
Bibliographic record
Abstract
A 73-year-old female underwent an endoscopic assessment of chronic dysphagia. Medical history includes remote Crohn’s disease with >25 intraabdominal surgeries and a remote cholecystectomy with hepaticojejunostomy due to calculi. Upper endoscopy revealed multiple non-traversable oesophageal webs, requiring a paediatric gastroscope. The stomach and duodenal bulb appeared normal, however, the second part of the duodenum demonstrated multiple lumens that became too narrow for gastroscope advancement (Figure 1A and 1B). No small bowel inflammation, masses, strictures, or surgical anastomoses were seen. Upper endoscopy views of a choledochoduodenal fistula are seen in the proximal second part of the duodenum. An elective computed tomography enterography demonstrated mild small bowel wall thickening with slight pseudosacculation and no inflammation. The endoscopic findings corresponded to a >1 cm choledochoduodenal fistula (CDF) (Figure 2A and 2B) between the second segment of the duodenum and proximal common bile duct, with resultant pneumobilia. The radiologist did not believe this represented a hepaticojejunostomy anastomosis. Retrospectively, pneumobilia can be seen on abdominal plain films as far back as 2015 (Figure 3). Coronal (A) and axial (B) cross-sections from an abdominal computed tomography enterography scan demonstrating a large choledochoduodenal fistula (identified by arrows). Abdominal x-ray demonstrating pneumobilia due to a large choledochoduodenal fistula. Potential causes of CDF in this patient include penetrating Crohn’s, iatrogenic from previous biliary surgery, and fistulizing choledocholithiasis. Conservative therapy was pursued due to fistula chronicity, absence of symptoms, and significant abdominal surgical history. CDFs represent 3.5% of bilioenteric fistulae.1 The most common causes are choledocholithiasis eroding into the duodenum and duodenal ulcer perforation.1 Symptoms can include epigastric pain, jaundice, and fever, and only 0.1% are asymptomatic.2 Endoscopic retrograde cholangiopancreatography provides direct visualization of the location/size of the fistula and the presence of any surrounding inflammation/masses/strictures.3 Treatment, if any, is based on aetiology, severity, and patient condition.3 None declared. None declared. In addition to this COI statement, ICMJE disclosure forms have been collected for all co-authors and can be accessed as supplementary material. There are no data associated with this manuscript.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.001 | 0.013 |
| Meta-epidemiology (narrow) | 0.003 | 0.002 |
| Meta-epidemiology (broad) | 0.002 | 0.003 |
| Bibliometrics | 0.007 | 0.003 |
| Science and technology studies | 0.006 | 0.005 |
| Scholarly communication | 0.002 | 0.004 |
| Open science | 0.002 | 0.002 |
| Research integrity | 0.011 | 0.007 |
| Insufficient payload (model declined to judge) | 0.004 | 0.001 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".