Background
Described in 1770, Bouveret’s syndrome is rare and characterized by gastric outlet obstruction caused by gallstone-driven fistulization between the gallbladder and the stomach or duodenum, accounting for 1-3% of gallstone ileus. Women with a mean age of 71 years are the primary demographic. 91% undergo surgical intervention for obstruction relief. Mortality ranges from 12-27%, with morbidity reaching 50%. We present a case of Bouveret’s syndrome with gallstone migration to the jejunum resulting in gallstone ileus, with the benefit of multiple imaging modalities. 

Case Presentation
A 54-year-old female presented with 4-day history of right upper quadrant abdominal pain. Ultrasound (US) elicited sonographic Murphy’s sign and showed gallbladder wall thickening and a gallstone. Subsequent computed tomography (CT) with contrast demonstrated cholecystitis, pneumobilia, and a cholecytoduodenal fistula. A large radiolucent gallstone was impacted in the duodenum resulting in gastric outlet obstruction. 

On hospital day 2, she developed vomiting with abdominal distension and a nasogastric tube provided relief. Abdominal radiographs showed new small bowel dilation concerning for small bowel obstruction (SBO). Magnetic resonance imaging (MRI) the following day redemonstrated cholecystitis and cholecystoduodenal fistula. Importantly, it also showed a new proximal SBO, with transition point in the jejunum, which was secondary to interval migration of the gallstone from duodenum to jejunum. 

Exploratory laparotomy was performed on hospital day 5 and a 5 cm cholelith was removed from the jejunum, relieving the obstruction. The patient tolerated the procedure well. She was discharged the following day and was stable at follow up. 

Discussion
This case illustrates the uncommon diagnosis of Bouveret’s syndrome with subsequent gallstone migration into the jejunum resulting in gallstone ileus with the benefit of US, CT, XR, and MRI imaging modalities. There is an average of 7 days from symptom onset to surgery, with 9 days for this patient. As mortality and morbidity rates are high, early diagnosis of Bouveret’s syndrome is crucial, which can be challenging due to its non-specific presentation of abdominal pain and vomiting, and because gallstones are frequently radiolucent making them difficult to detect on CT. The classic Rigler’s triad (ectopic gallstone, pneumobilia, and SBO) associated with gallstone ileus is not always visualized on imaging. CT is the most accurate imaging test for diagnosis of Bouveret’s syndrome and is therefore the imaging test of choice, although US and MRI can be very helpful adjunct to aid in detecting radiolucent gallstones, as in this case.

Multiple Imaging Modalities of Bouveret's Syndrome with Further Gallstone Migration

Background: 
Pancreatic pseudocysts occur relatively rarely in children as sequelae of pancreatitis. Giant pseudocysts measure over 10 cm in diameter, and pseudocysts 20 cm or over have rarely been reported in children, and optimal management is not clearly defined. We present a case of a child with a giant pancreatic pseudocyst after idiopathic necrotizing pancreatitis, and discuss management and clinical course. 
Case Presentation:
A 12-year-old otherwise healthy male presented with 4-day history of abdominal pain radiating to back, constipation, and vomiting. He was found to have SARS-CoV-2 infection without respiratory symptoms and acute necrotizing pancreatitis. His clinical course was mild. He was treated supportively and discharged after a 5-day hospital course with clinical improvement. 
Three weeks afterwards, the patient developed progressive early satiety, postprandial vomiting, and weight loss. The upper abdomen was distended with a visible, palpable mass. MRI showed a mature pancreatic pseudocyst measuring 20 x 11.3 x 16.1 cm without significant solid internal debris. Endoscopic ultrasound examination (EUS) with cystgastrostomy creation was performed with lumen apposing metal stent (LAMS) placement, and 2.5 L of brown fluid was drained. The patient tolerated the procedure well with abdominal mass resolution during the procedure. The following day, his abdomen was soft and non-tender to palpation with symptom resolution. He was discharged with plan for repeat CT to assess pseudocyst resolution and endoscopic cystgastrostomy stent removal if drainage was complete in 1 month. 
Patient presented 3 weeks after cystgastrostomy with abdominal pain and vomiting. Repeat endoscopy was performed and found stent occlusion with necrotic tissue. He underwent necrosectomy and LAMS replacement with two plastic pigtail stents for prolonged drainage with symptom resolution. Patient is asymptomatic with plans for repeat imaging in 3 months and stent removal if drainage is complete. 
Discussion: 
This case illustrates unusual development of a symptomatic giant pediatric pancreatic pseudocyst after idiopathic necrotizing pancreatitis, requiring intervention rather than conservative treatment. EUS drainage by cystgastrostomy stent insertion is an accepted treatment though few pediatric gastroenterologists are trained to perform this. Therefore, patients and families must travel or transfer to centers with appropriate expertise and resources.

Unusual Giant Pancreatic Pseudocyst Development in a Pediatric Patient after Necrotizing Pancreatitis

 Radiology / Nuclear Medicine / Radiation Oncology

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Vivian Lu

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Multiple Imaging Modalities of Bouveret's Syndrome with Further Gallstone Migration

Unusual Giant Pancreatic Pseudocyst Development in a Pediatric Patient after Necrotizing Pancreatitis

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