【Daily case 388 stage】A rare cause of abdominal pain in elderly men

Case information

The patient, a 71-year-old male, was admitted
to the hospital for 2 days for persistent epigastric pain.

CT of the abdomen at the time of visit to the hospital shows thickening of the duodenal wall (see Figure A
).

(Figure A as seen on CT examination of the outer hospital)

Physical examination: the patient is delirious, conscious, and uncooperative
.

The results of laboratory examination are as follows: WBC 9.

Upper gastrointestinal endoscopy shows a lump-like substance at the perforation of the duodenal pellet (see figure B), and pathological examination of the diseased tissue is taken microscopic for examination
.

(Figure B Upper gastrointestinal endoscopy as seen)

The patient has progressively worsened symptoms of bloating and signs of peritoneal irritation 6 hours after gastroscopy

【Thinking and Analysis】

What is the most likely diagnosis for this patient? Why do peritoneal irritation signs occur? What treatment is needed?

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Final diagnosis: duodenal ulcer ruptures into the liver

Follow-up CT shows a large amount of free gas under the diaphragm, perforation of duodenal ulcers and involvement of the left lobe of the liver (see Figure C, where the arrow shows).

(Figure C Review CT as seen)

Emergency laparoscopic perforation of a duodenal bulb ulcer and penetration into the inferior wall of the liver (see Figure D, arrows), and the surgical completion of the perforation site
was successful.

(Figure D Emergency laparoscopic as seen)

Pathological examination results show normal hepatocytes (see Figure E
).

(Figure E as seen on pathological examination)

【Discussion】

Ulcer perforation into the liver is a rare complication of peptic ulcer, and duodenal ulcer perforation into the liver is more common
than gastric ulcer perforation.

As shown in this example, endoscopy may reveal lumpy tissue
at the site of the ulcer perforation.

Most patients with ulcers perforated into the liver require surgery, and a few patients can be improved with proton-pump inhibitors or histamine H2 blockers
.