Bouveret's syndrome presenting as upper gastrointestinal hemorrhage without hematemesis.

A 74-year-old woman with a recent diagnosis of peptic ulcer disease diagnosed by endoscopy after presentation with an episode of upper gastrointestinal bleeding returned 6 1/2 weeks later with a 5-day history of nausea and vomiting without associated symptoms. An ultrasound was nondiagnostic except for a large gallstone and a poorly visualized gallbladder. Repeat endoscopy revealed a hard mass that was presumed to have formed secondarily to an ulcer-induced stricture, and a 6-cm filling defect just proximal to the duodenal bulb was seen on a preoperative upper gastrointestinal series. At laparotomy the mass was actually a large gallstone and two smaller stones, which had eroded into and become impacted in the duodenal bulb creating a gastric outlet obstruction. The stones were extracted via a duodenotomy, and the remaining portion of the gallbladder was removed with repair of the cholecystoduodenal fistula. The patient was discharged home after an uncomplicated postoperative course. Gastric outlet obstruction by a duodenal gallstone is a condition known as Bouveret's syndrome, which is a rare complication of gallstone disease. Upper gastrointestinal hemorrhage is an especially rare form of presentation.

Tissue expanders for abdominal wall reconstruction following severe trauma: technical note and case reports.

A technique of abdominal wall reconstruction without the use of prosthetic materials or myocutaneous flaps following severe abdominal trauma is described. Six weeks before abdominal reconstruction, tissue expanders are inserted on either side of the ventral defect and inflated at weekly intervals to increase the amount of local tissue for coverage. Restoration of the abdominal wall is accomplished by denuding the skin graft covering the ventral defect of its dermal elements and suturing this newly created fascial graft to the existing rectus fascia. The fascial graft is covered with full-thickness skin using local advancement flaps. This procedure has been carried out on two patients in conjunction with closure of a colostomy in one and closure of an enterocutaneous fistula in another. Both patients healed without infection, and follow-up at 3 and 12 months postoperatively demonstrated no evidence of hernia formation.