A Rare Cause of Upper Gastrointestinal Bleeding.

Sir,

We enjoyed the article by Dr. Ray-Offor and Dr. Elenwo “Endoscopic evaluation of upper and lower gastrointestinal bleeding,”[1] so we would like to thank authors. Reminding about the role of surgery in the treatment of gastrointestinal bleeding (GIB), we would like to share an unusual case of upper GIB (UGIB) treated surgically.

A 62-year-old male patient was admitted to Vladimir City Clinical Hospital of Emergency Medicine with 1-day history of melena, fatigue, and an episode of syncope about 2 h before admission. His past medical history was significant for Billroth-2 gastrectomy 3 years before admission due to severe duodenal ulcer bleeding. On admission, his pulse was 120 bpm, blood pressure 80/50 mmHg, hemoglobin - 9.8 mg/dL, hematocrit - 0.27, white blood cell - 18 × 109/l, band neutrophils - 12%, tenderness and palpable mass on epigastrium and right hypochondrium. On esophagogastroduodenoscopy erosive gastritis without signs of bleeding and extragastric compression of lesser curvature was revealed. Abdominal ultrasonography showed no masses and fluid collections; the walls of the colon in hepatic flexure thickened up to 1 cm. Computed tomography-colonoscopy revealed no changes in the large bowel. However, there was a subhepatic mass and free subhepatic and retroperitoneal gas [Figure 1]. Duodenal stump abscess was suspected. Contrast meal radiography revealed extragastric compression and duodenal stump leak [Figure 2]. The patient underwent laparotomy that revealed an “old” duodenal stump leak with subhepatic abscess [Figure 3]. The cause of bleeding appeared to be erosive hemorrhage from abscess walls to the duodenum via the stump defect. Primary repair of duodenal stump was performed. Postoperatively, enteral feeding via nasojejunal tube was started on the 1st day. On the 6th postoperative day, duodenal stump leak recurred which was treated conservatively. The patient was discharged on the 18th postoperative day.

Figure 1

Abdominal computed tomography. (a) Sagittal plane: Four arrows at the left show subhepatic mass with free gas in it, an arrow at the right shows retroperitoneal gas. (b) Sagittal plane: The cross at the left shows subhepatic mass, the arrow at the right shows retroperitoneal gas. (c) Axial plane: The upper arrow shows subhepatic mass with free gas in it, the lower arrow shows retroperitoneal gas. (d) Coronal plane: The arrow shows retroperitoneal gas

Figure 2

Contrast meal radiography. The white arrows show extragastric compression. The black arrow shows duodenal stump with ill-defined borders and extravasation of the contrast meal

Figure 3

Laparotomy. The arrow shows the abscess cavity around the duodenal stump. The defect of the duodenal stump is also seen clearly

The incidence of UGIB is 40–150/100,000 population per year with mortality of 6–10%, reaching even 30% in patients with hemorrhagic shock. Although surgery plays adjunctive role in the treatment of GIB, surgical treatment is used in only 3–15%.[2] Most of the UGIB cases requiring surgery are those with an extraluminal source such as hemobilia, hemosuccus pancreaticus, pancreatic pseudocysts eroding hollow viscus, or duodenal stump leak.

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