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
