0:01

So this next patient, uh, 65-year-old male with

0:05

nausea, vomiting, looking for a bowel obstruction.

0:08

They started off with a CT scan, and I

0:11

want to show you some of these images.

0:14

CT scan with intravenous contrast, and as you

0:17

scroll downwards, I think the first thing you

0:19

notice is the stomach is massively distended,

0:23

and has some content, ingested content

0:25

that's sort of layering within dependently.

0:29

You can see the distal stomach is distended, the

0:31

duodenum is distended over here, and really beyond

0:34

it, uh, all the loops of bowel look pretty okay.

0:37

It's really just the stomach and the duodenum

0:39

that's distended, uh, and, and essentially

0:42

results in a gastric outlet obstruction.

0:45

And so this was interpreted, uh, as such, and etiology

0:49

was not readily apparent, uh, on these images.

0:52

An MRI was obtained to see if there was

0:55

any sort of abnormality resulting in this.

0:59

So here we have the MRI.

1:00

I am going to start off.

1:01

This is a non-contrast MRI that was done, so I'll

1:03

start off with some of the T2-weighted sequences.

1:06

This is the axial T2 non-fat-saturated image.

1:10

They've put an NG tube in this patient.

1:11

That stomach has become decompressed in the interim,

1:15

but as you kind of scroll through, you notice

1:17

that in the duodenum there is a T2 hypo intense

1:22

structure that has this sort of geographic shape.

1:25

When I say that, look at the borders of this.

1:28

All right, this looks completely straight,

1:30

pretty straight hair, rounded border here.

1:32

And so that really is something

1:35

that we need to investigate more.

1:36

As you scroll upwards from here, you notice that

1:38

there's a similar looking, though smaller, structure,

1:41

which is T2 hypointense located, just cephalic to it.

1:45

And if you look in the T2 fat-saturated image,

1:49

this finding is, uh, is also readily apparent

1:53

as that geographic T2 hypointense structure.

1:57

The axial image on the coronal images as well,

1:59

you can see that this, uh, finding is present.

2:02

So it's sort of this consistent finding

2:03

that we can see just T2 hypointense.

2:07

And so I'm just going to have these two sets of images

2:10

right next to each other, the MRI and the CT scan.

2:16

And now if we scroll through the CT scan, we can

2:18

see that there is a gastric outlet obstruction.

2:20

And in retrospect, you can see that

2:22

there is that structure that's located

2:25

in a very, very similar location.

2:26

location on the CT scan.

2:28

And that's what's causing the

2:30

gastric outlet obstruction.

2:32

So we've seen this sort of signal and shapes

2:35

before, except we've seen them in the gallbladder.

2:38

And so in this instance, it's an example of a gallstone

2:41

that's sort of trapped in that first portion of the

2:44

duodenum resulting in gastric outlet obstruction.

2:47

And this has a name, we call it Bouveret syndrome.

2:52

And it's thought to occur due

2:55

to a cholecystoduodenal fistula.

2:59

The idea here is that it's patients who have recurrent

3:02

bouts of cholecystitis, and perhaps even have chronic

3:06

cholecystitis, and over time create these sort of

3:09

fistulous tracts to the distal stomach proximal

3:14

duodenum, through which stones can sort of enter.

3:17

and exit through and lodge inside

3:21

that proximal portion of the duodenum,

3:22

resulting in gastric outlet obstructions.

3:25

Very, very uncommon.

3:26

When you look at the cases of who gets Bouveret

3:29

syndrome, it's found more often in elderly females.

3:32

They present with nausea, vomiting, abdominal

3:34

pain, and it's just one of those things that's

3:37

an interesting, uh, but rare cause of gastric

3:40

outlet obstruction and something one should think

3:42

about when you have a massively distended stomach,

3:45

a filling defect in this location, uh, and

3:48

your encounter with a patient who's had

3:50

a history of prior, uh, abnormalities and

3:53

inflammation associated with the gallbladder.