ELECTRONIC IMAGE OF THE MONTH An Unusual Complication of a Duodenal Ulcer Emma L. Johnston,* Kamal V. Patel,* and Jason M. Dunn*,‡ *Department of Gastroenterology, Guy’s and St Thomas’ National Health Service Foundation Trust, St Thomas’ Hospital, London, United Kingdom; ‡Institute for Cancer Genetics and Informatics, Radiumhospitalet, Montebello, Oslo, Norway
n 86-year-old man presented to the Emergency Department with a 6-week history of severe, intermittent, colicky abdominal pain and diarrhea. The stool was dark in color and he was opening his bowels 4 to 5 times a day. There was no nausea but his appetite was reduced and he had lost more than 14 pounds in weight. He had a past medical history of hypertension and was on 50 mg atenolol, 4 mg doxazosin, and 2 mg trandolapril daily. He lived independently and was the main carer for his wife, who suffered from dementia. His initial physical examination showed a systolic blood pressure of 75 mm Hg that responded quickly to intravenous fluids, improving to 100/41 mm Hg. His pulse was normal at 80 bpm. The abdomen was soft with some mild periumbilical discomfort. No masses were palpable. Blood tests showed normocytic anemia, a hemoglobin level of 83 g/L, with increased inflammatory markers; his white cell count was 12.9 109 and his C-reactive protein level was 53 mg/L. He had an acute kidney injury, with a creatinine concentration of 114 mmol/L and a proportionally higher urea concentration of 18.4 mmol/L. He was not jaundiced and his liver function test results were normal apart from an albumin level of 32 g/L. Plain chest and abdominal radiographs were unremarkable. He was transfused with 3 units of packed red cells and underwent gastroscopy; endoscopic images of the duodenal bulb are shown in Figures A and B. The gastroscopy showed chronic inflammation and ulceration of the first part of the duodenum. Interestingly, 3 small holes were seen within the ulcer, through which air was bubbling into the duodenum.
A
He subsequently had a computerized tomography (CT) scan of his abdomen and pelvis. Axial images from the CT scan are shown in Figures C and D. The CT scan identified air within the intrahepatic bile ducts (Figure C), common bile duct (Figure D), and gallbladder. There also was thickening of the duodenum with adjacent fat stranding. A diagnosis was made of a chronic duodenal ulcer that had perforated, causing a choledochoduodenal fistula. The patient was started on broad-spectrum antibiotics, co-amoxiclav and metronidazole, and high-dose intravenous proton pump inhibitor (PPI) therapy. A subsequent magnetic resonance cholangiopancreatography confirmed a choledochoduodenal fistula. The patient made a good recovery without needing surgery and was asymptomatic when reviewed 2 months after discharge in the out-patient department. Choledochoduodenal fistulas are a rare complication of chronic duodenal ulcers, and are reported to occur in 0.3% to 0.5% of cases.1 The majority of choledochoduodenal fistulas (80%), however, are secondary to peptic ulcer disease. Previously, surgery, commonly a vagotomy and gastrectomy, was the preferred management option for choledochoduodenal fistulas resulting from peptic ulcer disease, but the introduction of acid suppression with H2-receptor antagonists and subsequently PPIs, has revolutionized treatment. Thus, the majority of patients require surgery only if they do not respond to PPI therapy.2 The presence of a choledochoduodenal fistula is a difficult diagnosis to make by clinical history and examination alone. It therefore is important that this is considered early as a differential diagnosis in patients
Clinical Gastroenterology and Hepatology 2015;-:-–-
ELECTRONIC IMAGE OF THE MONTH, continued who have air in the biliary tree who have not had a recent sphincterotomy or surgical intervention.
penetrated duodenal ulcer disease. Ann Gastroenterol 2004; 17:104–108.
References 1.
Michowitz M, Farago C, Lazarovici I, et al. Choledochoduodenal fistula: a rare complication of duodenal ulcer. Am J Gastroenterol 1984;79:416–420.
2.
Xeropotamos N, Nousias V, Vekris A, et al. Choledochoduodenal fistula: an unusual complication of
e2
Conflicts of interest The authors disclose no conflicts. © 2015 by the AGA Institute 1542-3565/$36.00 http://dx.doi.org/10.1016/j.cgh.2014.11.032
n 86-year-old man presented to the Emergency Department with a 6-week history of severe, intermittent, colicky abdominal pain and diarrhea. The stool was dark in color and he was opening his bowels 4 to 5 times a day. There was no nausea but his appetite was reduced and he had lost more than 14 pounds in weight. He had a past medical history of hypertension and was on 50 mg atenolol, 4 mg doxazosin, and 2 mg trandolapril daily. He lived independently and was the main carer for his wife, who suffered from dementia. His initial physical examination showed a systolic blood pressure of 75 mm Hg that responded quickly to intravenous fluids, improving to 100/41 mm Hg. His pulse was normal at 80 bpm. The abdomen was soft with some mild periumbilical discomfort. No masses were palpable. Blood tests showed normocytic anemia, a hemoglobin level of 83 g/L, with increased inflammatory markers; his white cell count was 12.9 109 and his C-reactive protein level was 53 mg/L. He had an acute kidney injury, with a creatinine concentration of 114 mmol/L and a proportionally higher urea concentration of 18.4 mmol/L. He was not jaundiced and his liver function test results were normal apart from an albumin level of 32 g/L. Plain chest and abdominal radiographs were unremarkable. He was transfused with 3 units of packed red cells and underwent gastroscopy; endoscopic images of the duodenal bulb are shown in Figures A and B. The gastroscopy showed chronic inflammation and ulceration of the first part of the duodenum. Interestingly, 3 small holes were seen within the ulcer, through which air was bubbling into the duodenum.
A
He subsequently had a computerized tomography (CT) scan of his abdomen and pelvis. Axial images from the CT scan are shown in Figures C and D. The CT scan identified air within the intrahepatic bile ducts (Figure C), common bile duct (Figure D), and gallbladder. There also was thickening of the duodenum with adjacent fat stranding. A diagnosis was made of a chronic duodenal ulcer that had perforated, causing a choledochoduodenal fistula. The patient was started on broad-spectrum antibiotics, co-amoxiclav and metronidazole, and high-dose intravenous proton pump inhibitor (PPI) therapy. A subsequent magnetic resonance cholangiopancreatography confirmed a choledochoduodenal fistula. The patient made a good recovery without needing surgery and was asymptomatic when reviewed 2 months after discharge in the out-patient department. Choledochoduodenal fistulas are a rare complication of chronic duodenal ulcers, and are reported to occur in 0.3% to 0.5% of cases.1 The majority of choledochoduodenal fistulas (80%), however, are secondary to peptic ulcer disease. Previously, surgery, commonly a vagotomy and gastrectomy, was the preferred management option for choledochoduodenal fistulas resulting from peptic ulcer disease, but the introduction of acid suppression with H2-receptor antagonists and subsequently PPIs, has revolutionized treatment. Thus, the majority of patients require surgery only if they do not respond to PPI therapy.2 The presence of a choledochoduodenal fistula is a difficult diagnosis to make by clinical history and examination alone. It therefore is important that this is considered early as a differential diagnosis in patients
Clinical Gastroenterology and Hepatology 2015;-:-–-
ELECTRONIC IMAGE OF THE MONTH, continued who have air in the biliary tree who have not had a recent sphincterotomy or surgical intervention.
penetrated duodenal ulcer disease. Ann Gastroenterol 2004; 17:104–108.
References 1.
Michowitz M, Farago C, Lazarovici I, et al. Choledochoduodenal fistula: a rare complication of duodenal ulcer. Am J Gastroenterol 1984;79:416–420.
2.
Xeropotamos N, Nousias V, Vekris A, et al. Choledochoduodenal fistula: an unusual complication of
e2
Conflicts of interest The authors disclose no conflicts. © 2015 by the AGA Institute 1542-3565/$36.00 http://dx.doi.org/10.1016/j.cgh.2014.11.032
