Intramural Duodenal Abscess Secondary to Cholecystitis of Remnant Gallbladder: A Case Report

Abstract

Introduction: Gastric outlet obstruction (GOO) has various causes, commonly related to malignancy and peptic ulcer disease. Intramural duodenal abscess is a rare cause of GOO and sparsely reported in literature. Case Presentation: 88-year-old female presented with clinical symptoms of GOO. Surgical history included open partial cholecystectomy. Medical management was initiated with proton pump inhibitors (PPI) and nasogastric tube decompression. Initial labs revealed anemia (11.8), leukocytosis (14.6) and normal liver function tests. Computer tomography identified inflammatory versus neoplastic mass involving gallbladder, duodenum and antrum (Figure 1). Magnetic resonance cholangiopancreatography denoted irregular mass of duodenum abutting the gallbladder. Esophagogastroduodenoscopy revealed polypoid duodenal mass partially obstructing the duodenal bulb. Biopsies discovered inflammation. Hepatobiliary surgery recommended completion cholecystectomy, transduodenal mass resection, and possible biliary reconstruction. Given age and nutritional status, pancreaticoduodenectomy was not entertained. Intraoperatively, remnant gallbladder was adhered to first portion of duodenum. The pylorus and proximal duodenum were firm concerning for malignancy compared to duodenal polyp. Frank purulence was noted during completion cholecystectomy. Proximal duodenum was thin requiring resection, along with pylorus and distal gastrectomy followed by Billroth II gastrojejunostomy. Surgical pathology revealed chronic intramural duodenal abscess causing GOO. Patient recovered to independent living after brief LTAC stay. Conclusion: PPIs have decreased surgical intervention necessity and benign causes of GOO. However, intramural duodenal abscess needs consideration in patients with subtotal cholecystectomy history superposed with acute cholecystitis and presentation of GOO. Surgical resection is beneficial in this clinical scenario.