Boulder Dash: Endoscopic Management of Bouveret Syndrome and Gallstone Ileus
Bibliographic record
Abstract
CASE REPORT A 68-year-old woman with metastatic colon adenocarcinoma presented with 2 weeks of nausea and emesis. She was nontoxic appearing with soft, nontender, and nondistended abdomen. A computed tomography (CT) scan demonstrated a cholecystoduodenal fistula with migration of a 3.0 × 5.1 cm gallstone into the duodenal bulb with associated gastric distention, consistent with Bouveret syndrome (Figure 1). The cholecystoduodenal fistula was suspected to have developed spontaneously, possibly exacerbated by the prior use of bevacizumab.Figure 1.: (A) Coronal CT abdomen and pelvis demonstrating gallstone within the duodenal bulb and resulting gastric distention. (B) Gallstone located at the duodenal bulb visualized on EGD. (C) Coronal CT abdomen and pelvis demonstrating gallstone fragment within the small bowel leading to small bowel obstruction.An esophagogastroduodenoscopy showed an obstructing stone in the duodenal bulb (Figure 1). Endoscopic electrohydraulic lithotripsy was used to fragment the stone; large fragments >1.5 cm were subsequently removed with a retrieval net while smaller fragments were irrigated into the downstream duodenum. Recurrent symptoms prompted a repeat CT showing distal migration of stone fragments causing ileal obstruction. Colonoscopy identified a malignant ileocecal valve stricture. A 25 × 90 mm uncovered metal stent was placed across the stricture with subsequent flow of small gallstone fragments. Repeat CT showed gallstone fragments in the proximal end of the stent with upstream small bowel dilation (Figure 1). Repeat colonoscopy visualized stone fragments in the left colon, which were removed. The previously placed stent had expanded allowing traversal, and the obstructing stone fragment was removed. This case illustrates the successful endoscopic management of a unique presentation of Bouveret syndrome with subsequent gallstone ileus. DISCLOSURES Author contributions: W. Hirsch: draft writing, draft review, organization, inception; B. Megna: inception, draft review; N. Azeem: draft review, project oversight, final approval, and is the article guarantor. Financial disclosure: N. Azeem: consultant for Boston Scientific. Previous presentation: This project was presented as a poster at the ACG 2023 Annual Scientific Meeting; October 24, 2023; Vancouver, BC, Canada. Informed consent was obtained for this case report.
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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 | 0.000 | 0.002 |
| Meta-epidemiology (narrow) | 0.001 | 0.001 |
| Meta-epidemiology (broad) | 0.001 | 0.001 |
| Bibliometrics | 0.002 | 0.001 |
| Science and technology studies | 0.002 | 0.001 |
| Scholarly communication | 0.001 | 0.001 |
| Open science | 0.001 | 0.001 |
| Research integrity | 0.004 | 0.002 |
| Insufficient payload (model declined to judge) | 0.001 | 0.000 |
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".