Presentation
History of partial gastrectomy for gastric cancer a few months ago now referred with rectorrhagia.
Patient Data
Evidence of partial gastrectomy and Billroth II gastrojejunostomy is seen, without any sign of anastomosis recurrence. The ingested contrast material passes through the patent duodenal stump into a cavity. The cavity is confined superiorly by underneath of the left liver lobe, inferiorly by the transverse colon, and medially by the gallbladder, and fistulized to the two hollow organs. A part of the cavity is within the left liver lobe. The liver parenchyma in the superior wall of the cavity shows liquefaction and multiple air bubbles in favor of gas-forming infection. Multiple hepatic masses in favor of metastases, severe ascites, and a few peritoneal implants are visible. An anterior abdominal wall tumoral implant is seen, which invades a part of the efferent loop behind it, about 40- 50 cm after gastrojejunostomy with minimal proximal bowel dilation. Significant bowel obstruction is not present.
The black arrow points to the liquified infected liver tissue at the superior edge of the intrahepatic cavity (shown with the dark red arrow).
The green arrow shows the gallbladder, that fistulized to the mentioned cavity. The yellow arrow depicts the duodenal stump that is patent with free contrast passage to the cavity. The red shows the site that the cavity, fistulized to the transverse colon. The blue arrows point to the peritoneal implants and the orange to liver metastasis. The brown and pink arrows depict the abdominal wall implant and the jejunal loop that was invaded by it, respectively.
Case Discussion
Findings are likely explained with a missed duodenal stump leakage, that had been sealed by mentioned neighboring organs and eventually leads to fistulization and hepatic parenchymal gas-forming infection.