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Ulcère Perforé-Bouché

Bazerbachi, Fateh MD1; Chandrasekhara, Vinay MD2

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The American Journal of Gastroenterology: May 2020 - Volume 115 - Issue 5 - p 649
doi: 10.14309/ajg.0000000000000389
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An 84-year-old woman presented with 3 months of epigastric pain. Medical history included chronic use of over-the-counter nonsteroidal anti-inflammatory drugs. Cross-sectional imaging of the abdomen showed a hypoattenuating mass in the pancreatic body, suspicious for pancreatic adenocarcinoma. Physical examination showed epigastric tenderness, without peritonitis. She was referred for an outpatient endoscopic ultrasound. Endoscopy showed a healed granulated defect in the anterolateral wall of the duodenal bulb and a fistulous tract, through the hepatoduodenal ligament, leading to the liver surface which was covered with the lesser omentum (a and b). Under fluoroscopy, contrast through the duodenal fistula delineated the walled-off lesser sac cavity (c). The abdominal examination remained unchanged throughout, and the patient was discharged from the endoscopy suite uneventfully. Typically, penetrating peptic ulcer disease into the liver presents with dramatic symptoms, such as peritonitis or severe gastrointestinal hemorrhage. When the ulcer site is directly tamponaded by adjacent organs (e.g., liver, pancreas, spleen), this leads to a contained perforated ulcer (Ulcère Perforé-Bouché), which may be an incidental endoscopic finding. When discovered, gas insufflation during the endoscopy may cause a leak, leading to abdominal catastrophe. In this case, fluoroscopy ruled out an iatrogenic sheering of the preexisting walled-off cavity. (Informed consent was obtained from the patient to publish these images.)

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