Pus from the pylorus: an unusual endoscopic finding suggestive of periduodenal abscess

Subphrenic intra-abdominal abscess is a well-documented complication of perforated duodenal ulcers [1] [2] [3] [4] [5]. We report here on an unusual endoscopic finding of a sutured perforated duodenal ulcer associated with a subphrenic abscess.

A 32-year-old man in whom a perforated duodenal ulcer had been surgically closed with laparotomy 3 weeks previously presented to our emergency department with symptoms of persistent epigastralgia and fever. At esophagogastroduodenoscopy, abundant whitish pus was noted streaming from the pylorus into the gastric antrum (Figure [1]). The source of the pus was a large duodenal ulcer in the deformed duodenal bulb, where surgical sutures remained (Figure [2]). A reformatted computed-tomographic image identified a fistula (Figure [3]) between a subphrenic abscess and the duodenal bulb, accounting for the origin of the pus stream in the stomach. The patient received percutaneous drainage of the subphrenic abscess, parenteral antibiotics, and proton-pump inhibitors. Therapy to eradicate Helicobacter pylori was prescribed. He made an uneventful recovery without a repeat operation and remained well during a 6-month follow-up period.

Figure 1 Endoscopic image, showing abundant whitish pus streaming from the pylorus into the gastric antrum.

Figure 2 Endoscopic image, showing the pus originating from a sutured duodenal ulcer in the deformed duodenal bulb.

Figure 3 A reformatted computed tomogram, showing a fistula (arrow) communicating between the subphrenic abscess (see additional figure in the right lower corner) and the duodenal bulb.

This case illustrates that a stream of pus in the stomach, particularly when it is accompanied by signs of infection, should suggest to endoscopists the possibility of a subphrenic abscess draining into the gastrointestinal tract.

Endoscopy_UCTN_Code_CCL-1AB-2AZ-3AC

References

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