© Georg Thieme Verlag KG Stuttgart · New York
Pus from the pylorus: an unusual endoscopic finding suggestive of periduodenal abscess
03 August 2007 (online)
Subphrenic intra-abdominal abscess is a well-documented complication of perforated duodenal ulcers     . 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 ). The source of the pus was a large duodenal ulcer in the deformed duodenal bulb, where surgical sutures remained (Figure ). A reformatted computed-tomographic image identified a fistula (Figure ) 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.
- 1 Allard J C, Kuligowska E. Percutaneous treatment of an intrahepatic abscess caused by a penetrating duodenal ulcer. J Clin Gastroenterol. 1987; 9 603-606
- 2 Albu E, Moreira D, Faltous A. et al . Intramural abscess of the duodenum resulting from perforated peptic ulcer. South Med J. 1995; 88 1078-1080
- 3 Yoshida H, Onda M, Tajiri T. et al . A case of abscess caused by a penetrating duodenal ulcer. Hepatogastroenterology. 1999; 46 2379-2381
- 4 Chau W K, Chan S C. Sonographic diagnosis of a small fistulous communication between a subphrenic abscess and a perforated duodenal ulcer. J Clin Ultrasound. 2000; 28 153-156
- 5 Mimica M. Silent free perforation of duodenal ulcer in an elderly patient presenting with melena: management directed by upper endoscopy and percussion of the liver. Endoscopy. 2001; 33 387
H. P. Wang, M. D.
Dept. of Emergency Medicine
National Taiwan University Hospital and National Taiwan University College of Medicine
7 Chung-Shan South Road