A Rare Complication of Recurrent Duodenal Ulcer

Abstract

Question: A 92-year-old man presented to our emergency department owing to black stool passage for 3 days with general fatigue. He had history of bilateral renal cysts and duodenal bulb ulcer bleeding post suture ligation 6 months ago. On examination, his conjunctiva were pale and his abdomen was soft without tenderness. Digital rectal examination revealed tarry stool. Laboratory data exhibited anemia (hemoglobin, 6.9 g/dL). Esophagogastroduodenoscopy revealed a 2.5-cm bleeding ulcer at the distal bulb and one 1-cm outpunching area at the proximal second portion of the duodenum with internal debris (Figure A, B). Computed tomography (CT) of the abdomen (Figure C) and further upper gastrointestinal series were performed (Figure D, E). What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. A CT of the abdomen revealed a 5.4-cm right renal cystic lesion with internal food material and gas pockets that is connected to the second portion of the duodenum (Figure C, arrow). Further upper gastrointestinal series disclosed a focal out-pouching with contrast accumulation arising from the second portion of duodenum and pointing posteriorly (Figure D, E), compatible with a duodenal-renal fistula as diagnosed in CT study. The inflammatory response to a penetrating peptic ulcer can lead to the formation of a fistula between the duodenum and any structure nearby. Fistulae to the biliary tract and colon has been described more commonly. Duodenal-renal fistulae owing to peptic ulcer disease is very rare and unique. The patient was transferred to general surgeon and he was discharged eventfully 34 days later under conservative treatment.