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Bouveret's syndrome involves gastric outlet obstruction caused by a gallstone in the duodenum. This type of gallstone ileus can be diagnosed and treated endoscopically. Endoscopic stone removal is especially indicated in poor risk patients. A dislodged impacted stone can migrate distally and cause small bowel mechanical obstruction. We report a 51-year-old woman who underwent endoscopic duodenal stone manipulation which resulted in small bowel obstruction.

The buried gastrostomy bumper syndrome is one of the rare complications of PEG (percutaneous endoscopic gastrostomy) insertion. It develops when there is a combination of a rigid bumper and a tension build-up between internal and external bumpers. This condition is manifested by complete occlusion of the internal opening of the gastrostomy by mucosa, making it impossible to feed the patient. We report a case in which the PEG was inserted a year prior to the appearance of this rare complication. It was embedded beneath the gastric mucosa and we had difficulty in removing it to insert a new PEG. The bumpers are anchor-like attachments to each end of the gastrostomy, which keep it stationary. The rigid bumper is an integral part of the gastrostomy. However, a "soft" bumper has been developed, but its costliness has restricted its use. In our case the gastrostomy was removed with the aid of the cutting wire of a sphincterotome in light contact with the external tissue.

A case of a large gastric phytobezoar (5 x 8 cm) is presented. It was diagnosed at operation in the stomach of a post vagotomy-pyloroplasty patient, and all attempts at removal (crushing, lavage and diathermy) failed. Complete removal of the phytobezoar was accomplished in 3 endoscopy sessions using a very large snare introduced through an overtube. The patient was told to refrain from cellulose- and fiber-rich food (such as persimmons and oranges) and was given prokinetic drugs, including cisapride, domperidone and metoclopramide.

A 2.5 kg female neonate, born after a normal 39-week pregnancy to Arab parents (1st degree cousins), developed unremitting vomiting of gastric contents, not bile-stained. Barium study demonstrated a grossly distended stomach with complete obstruction of the outlet. At laparotomy, pyloric atresia and a heterotopic pancreas located subserosally on the antrum of the stomach were diagnosed. A 3-cm gap was measured between the occluded antrum and the duodenum. Transmesocolic gastrojejunostomy was performed, and oral feeding was started 5 days later. Pyloric atresia and heterotopic pancreas are both rare congenital malformations. To the best of our knowledge, the combination of pyloric atresia and heterotopic pancreas has not previously been reported.