Endoscopy 2007; 39: E235-E236
DOI: 10.1055/s-2006-944900
Unusual cases and technical notes

© Georg Thieme Verlag KG Stuttgart · New York

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

C. C. Chen1 , T. C. Lee2 , K. L. Liu3 , J. T. Lin1 , H. P. Wang4
  • 1Dept. of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin, Taiwan
  • 2Dept. of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
  • 3Dept. of Medical Imaging
  • 4Dept. of Emergency Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
Further Information

Publication History

Publication Date:
03 August 2007 (online)

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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  • 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
Taipei 100
Taiwan

Fax: +886-2-23223150

Email: wanghp@ntu.edu.tw