Penetrating peptic ulcers often lead to severe complications. The development of uretero-enteric fistulas is rare and can be challenging to diagnose and treat. Here, we present the case of a 41-year-old patient who previously underwent gastrojejunostomy for superior mesenteric artery syndrome and developed a peptic jejunal ulcer, leading to a uretero-jejunal fistula and finally causing acute pyelonephritis. The patient was managed with a multidisciplinary approach including medical therapy and endoscopic and radiologic interventions.

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Luminal stent placement for malignant gastric outlet obstruction is an efficacious alternative to surgical bypass in patients with advanced malignancy and limited life expectancy. Altered surgical anatomy, especially Roux-en-Y gastric bypass (RYGB) anatomy, can make endoscopic intervention challenging. EUS-guided access to the remnant stomach using a lumen-apposing metal stent (LAMS), recently termed gastric access temporary for endoscopy (GATE), has been used to perform endoscopic submucosal dissection, EUS-guided tissue sampling, and various pancreaticobiliary interventions. We present a case using a variant of the GATE technique to allow endoscopic palliation of malignant gastric outlet obstruction of the remnant stomach (Video 1, available online at www.VideoGIE.org).