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Key Clinical Message: The case highlights the importance of decisive action in addressing large gallstones causing gastric outlet obstruction. The chosen single-stage surgical approach reflects the need to manage both obstruction and the gallstone simultaneously. Abstract: Bouveret's syndrome is a rare cause of gastric outlet obstruction secondary to gallstones entering the enteric system through an acquired cholecystoduodenal fistula. Here, we present the case of an 85-year-old female who presented to our emergency department with gastric outlet obstruction secondary to a large gallstone in the third part of the duodenum. Abdominal X-ray did not demonstrate air-fluid levels but revealed a dilated gastric shadow, suggesting gastric outlet obstruction. EGD showed a dilated stomach and a hard, golf ball-sized gallstone in the duodenum. CT scan showed a distended stomach with a large gallstone obstructing the DJ junction and air in the biliary tree. Findings were suggestive of perforation of the gallbladder with stone impaction in the duodenojejunal (DJ) junction. The patient was managed surgically with a one-stage procedure comprising enterotomy, fistula closure, and cholecystectomy. Although Bouveret's syndrome is rare, it is important for practicing surgeons to have a high index of suspicion for this condition due to the high mortality associated with it.
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Background and objectives Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been the cause of a worldwide outbreak of respiratory illness, which has been declared as coronavirus disease 2019 (COVID-19) pandemic by the World Health Organization (WHO). The outbreak has posed a huge challenge to countries around the world and has resulted in a global lockdown. The pandemic has especially overburdened the healthcare sector, resulting in a shortage of personnel and equipment. Along with many other manifestations, it has resulted in stress and anxiety for the physicians as well. Furthermore, many healthcare workers have been reluctant in treating COVID-19 patients. This study aimed to explore the concerns of physicians in the context of the COVID-19 pandemic and to evaluate the reasons for their reluctance to treat the patients. Methodology This descriptive cross-sectional study included 235 physicians from seven hospitals of Pakistan who were actively working amid the COVID-19 pandemic. Data were collected from March 1, 2020, to May 30, 2020, using a structured online questionnaire. Participants were approached via non-probability convenient sampling. Two hundred and eight respondents were included in the data analysis. SPSS Statistics version 23.0 (IBM Corp., Armonk, NY) was used for data entry and analysis. Results A striking 83.7% (n=174) of the respondents expressed their reluctance to treat patients with COVID-19. Concerns they raised included one or more of the following four reasons; lack of proper personal protective equipment (PPE), fear of self-infection, excessive workload, and fear of transmitting the infection to their family members. Of note, 92% (n=161) of the respondents reported a lack of PPE while 74.1% (n=129) reported fear of transmitting the infection to their family members as reasons for their reluctance. The vast majority of the participants reported the need for psychological training to treat the patients' anxiety (95.2%, n=198). Many participants were afraid that their own anxiety might be affecting the quality of care patients were receiving (67.3%, n=140). Hence, most of the participants reported that psychological counseling should be provided (93.3%, n=194). Participants with family members older than 60 years were found to be reluctant to treat patients due to the risk of transmitting the infection to them (69.7%, n=145, p=0.001). Therefore, a major proportion of the participants (96.2%, n=200) felt that the hospitals should provide a place for them to rest and temporarily isolate themselves to avoid coming into contact with their family members. Conclusions We conclude that a major proportion of physicians is reluctant to treat their patients due to multiple factors. The grave situation of the pandemic has taken a toll on their mental health, which could be affecting the quality of care that the patients receive. Their concerns should be addressed to not only provide them with support and improve their working environment but also to ensure that they are fully equipped to provide state-of-the-art care to the patients in these grave times.