Bouveret's syndrome is a rare cause of gastric outlet obstruction. Its diagnosis is often delayed or overlooked. It is characterized by the passage of a large gall bladder stone through a bilio-duodenal fistula, which becomes lodged in the duodenum causing duodenal obstruction. We report the case of a 70-year-old male with a history suggestive of gall bladder disease over a 1-year period. The diagnosis was confirmed by ultrasound, which showed a single large gall bladder stone and the patient was planned for elective laparoscopic cholecystectomy. One week prior to the elective surgery he presented with upper gastrointestinal bleeding for which he was admitted, diagnosed by a gastroenterologist as bleeding duodenal ulcer and treated by local epinephrine injection and blood transfusion. One week later he presented with a picture of acute gastric outlet obstruction, which proved by endoscopy to be due to a large stone impacted in the duodenum. Endoscopic management failed and the stone was managed by open surgery. The patient made a good postoperative recovery and for the last year he has remained free of symptoms.
AIM:To estimate the prevalence of celiac disease (CD) in adult patients with presumed irritable bowel syndrome (IBS).
METHODS:Between March 2005 and December 2008, 742 consecutive patients (293 male, median age 43 years, range 18-69 years) fulfilling the Rome Ⅱ criteria for IBS were prospectively enrolled in the study. IBS was diagnosed via self-completed Rome Ⅱ modular questionnaires. Anti-tissue transglutaminase (anti-tTG) serology was checked to initially recognize possible CD cases. Patients with a positive test were offered endoscopic duodenal biopsy to confirm the diagnosis of CD.
RESULTS:Thirty two patients (15 male, median age 41 years, range 19-59 years) were found to have organic diseases other than CD. Twenty four patients tested positive for anti-tTG antibodies, and duodenal biopsies confirmed the diagnosis in all of them. Thus, in this patient population with presumed IBS, 3.23% actually had CD.
CONCLUSION:CD is common in patients with presumed IBS. Routine screening for CD in patients with symptoms of IBS is recommended.
Although there is a high support among doctors for the promotion of EBM, there is a deficit in knowledge and skills of EBM. Hence, the time appears ripe for planning and implementing an effective EBM educational programme for both undergraduate and postgraduate doctors.