Hepatic penetration by stomal ulcer: rare complication of a peptic ulcer

A 57-year-old man, who had undergone a Billroth I partial gastrectomy for a duodenal ulcer 1 year previously, was hospitalized for continual epigastric pain over the past 1 month. Laboratory testing revealed anemia (hemoglobin 9.4 g/dL; normal range 13.5 – 16.9) and an elevated C-reactive protein level (2.22 mg/dL; normal < 0.02). Liver function tests and the serum gastrin level were within normal limits. Abdominal ultrasound revealed fluid and air bubbles in the liver ([Fig. 1 a]), moving between the liver and stomach through a fistula ([Fig. 1 b]). Computed tomography (CT) verified the ultrasound findings ([Fig. 2]). Endoscopy revealed a large ulcer in the duodenum near the anastomosis ([Fig. 3]). An endoscopic biopsy of the ulcer was negative for malignancy. The patient was diagnosed as having a stomal ulcer that had penetrated the liver, and he was subsequently treated with an H2 blocker and intravenous antibiotics. The ulcer healed after 1 month of treatment ([Fig. 4]). After discharge, the patient continued to take proton pump inhibitors (PPIs), and there has been no recurrence of the ulcer during the 7-year follow-up period.

Fig. 1 Abdominal ultrasound findings in a 57-year-old man with a history of Billroth I partial gastrectomy and hospitalized for continual epigastric pain. a Sagittal section of the upper abdomen showing an echo-free space with air bubbles (arrowhead) in the liver. b Coronal section of the upper abdomen showing fluid with air bubbles (arrowhead) moving between the liver and stomach through a fistula.

Fig. 2 Contrast-enhanced computed tomography (CT) showing fluid with air in the liver and a fistula between the hepatic lesion and the stomach.

Fig. 3 Endoscopic findings. a An ulcer (arrow) is seen in the duodenum near the suture. b Close-up view of the large, deep ulcer.

Fig. 4 Repeat endoscopy on day 35 showed the healed ulcer.

The most common site of penetration by duodenal ulcers is the pancreas (52.6 %), followed by the biliary tract (18.4 %), gastrohepatic omentum (10.7 %), liver (6.2 %), and colon (1.5 %) [1]. Most cases of hepatic penetration have been diagnosed intraoperatively and/or by endoscopic biopsy [1] [2]. However, in our patient, the ultrasound clearly demonstrated detailed findings sufficient for diagnosis. Most cases of ulcers penetrating the liver have been treated by surgical procedures [1] [2]. In addition to the present report, there have been two other recent case reports that have demonstrated the effectiveness of medical treatments such as H2 blockers and PPIs [3] [4].

Endoscopy_UCTN_Code_CCL_1AB_2AZ_3AZ

Competing interests: None

• References

• 1 Haubrich WD. Complications of peptic ulcer disease. In: Bockus HE, ed. Gastroenterology. Volume 1, 3rd edn. Philadelphia: WB Saunders; 1976: 720-762
• 2 Somi MH, Tarzamni MK, Farhang S et al. Liver mass due to penetration of a silent duodenal ulcer. Arch Iran Med 2007; 10: 242-245
• 3 Park RH, Russell RI. Liver penetration by peptic ulcer. Am J Gastroenterol 1988; 83: 793-795
• 4 Kayacetin E, Kayacetin S. Gastric ulcer penetrating to liver diagnosed by endoscopic biopsy. World J Gastroenterol 2004; 10: 1838-1840