Presentation
Known case of gastric cancer, who underwent total gastrectomy a few days ago, now has an ill appearance and tachycardia.
Patient Data
Evidence of total gastrectomy and esophagojejunostomy is visible. An about 1 cm mural defect is present at the anterior aspect of the esophagojejunostomy anastomosis. Free leakage of ingested oral contrast via the defect into a cavity in the upper abdomen is visible. The cavity contains air beside the oral contrast and ends at the site of a drain that is no longer in place. Another fluid collection is present adjacent to the duodenal stump but without contrast extravasation. A small focus of infarct is visible in the anterior pole of the spleen.
The black arrow points to the esophagojejunostomy anastomosis defect and the red extravasated oral contrast. The yellow arrow depicts the collection adjacent to the duodenal stump, and the pink shows splenic infarct.
With the diagnosis of esophagojejunostomy leakage, endoscopic stent placement is done. About 3-4 weeks later, the patient return with fever, and again CT scan was done(box below).
Evidence of metallic stent placement across the esophagojejunostomy site is visible. Free contrast leakage is not seen, but faint persistent leakage is suspected (seen between the stent and a drain). Contrast leakage is now visible in the collection adjacent to the duodenal stump, confirming duodenal stump leakage.
The red arrows depict the contrast extravasation to the collection adjacent to the duodenal stump. Suspected esophagojejunostomy leakage is not annotated and is hardly visible at a level that the stent and the drain are visible.
Case Discussion
The diagnosis of duodenal stump leak is challenging. Because of antegrade peristalsis of the pancreaticobiliary limb, the ingested oral contrast usually does not reach the duodenal stump, and the direct signs such as contrast extravasation are not usually present in duodenal stump leak. Indirect signs such as extraluminal air bubbles or fluid collection adjacent to the stump should raise the suspicion of the stump leakage. It is an important complication because of the pancreaticobiliary content of secretions.
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