A 61-year-old man was presented to our department with epigastric discomfort, general weakness, weight loss (~14 kg in 4 months), constipation, melena and vomiting for the last 4 months of solid intake 1 h after each meal. There was a good tolerance to liquid intake.\nPhysical examination revealed that the patient was afebrile, slightly pale, hemodynamically stable with no jaundice. We noticed an abdominal scar of midline incision and a mild tenderness in epigastrium. No organomegaly was found.\nPreviously, 1 month ago, the patient was admitted for the same complaints. He underwent upper gastrointestinal endoscopy which was unsuccessful because of the residual food in his stomach. The patient was put on omeprazole 20 mg twice daily with a re-evaluation after a month.\nThe patient’s past surgical history included perforated benign first portion of duodenal ulcer 15 years ago (treated by primary closure and graham patch) and cholecystoctomy with no other significant medical history.\nAdmission work-up is shown in Table .\nAn upper gastrointestinal endoscopy was performed again after having the patient fast overnight with these findings (Fig. ): residual food in stomach, pyloric edema and severe stenosis of the bulb that prevented us from progressing further into the small intestine. Biopsies were taken from the bulb and the atrophic mucosa of antrum. Histopathology revealed mild chronic atrophic gastritis and non-specific chronic duodenitis with no findings of either helicobacter pylori infection or malignancy. Colonoscopy, on the other hand, was within normal.\nIntravenous contrast computed tomography showed thickening of proximal gastric and pyloric walls and a mild dilatation of extra- and intra-hepatic bile ducts, although the head of pancreas was normal (Fig. ).\nThe primary diagnosis was gastric outlet obstruction due to a complicated benign duodenal ulcer. The diagnosis was based on the benign endoscopic histopathology findings of the bulb and the rarity of duodenal malignancy. The decision then was to perform elective laparotomy because of both refractory symptoms despite of medical treatment with proton pump inhibitors and the lack of medical experience in endoscopic dilation in the hospital. During surgery, we found severe adhesions caused by the previous surgery which required careful adhesiolysis. The stomach was dilated and thick-walled. A stenosis of duodenal bulb was also detected. Surprisingly, we palpated a mass (5 × 7 cm) arising from the posterior lower half of greater curvature extending to the lesser sac. Anatomically, this mass (Fig. ) represents a gastro-duodenal fourth segment fistula.\nThe surgical steps were (Fig. ): Antrectomy, resection of the fourth duodenum, end to end third duodenojejunostomy, Omega-Braun gastrojejunostomy, feeding jejunostomy and drainage. Histopathology study revealed a perforated benign gastric ulcer (Fig. ).\nWith a strict post-operative follow-up (shown in Table ) for the patient, he was discharged home in 9 days.
A 65-year-old female with history of chronic alcohol use was hospitalized for sudden onset of hematemesis. She also reported few days of nausea and vomiting associated with worsening ascites. She denied any significant past medical history except for a ruptured ovarian cyst at age of 30 years that required emergent surgery. Patient had a long history of alcohol use (two glasses of vodka daily) for over 10 years. Physical exam showed scleral icterus, there was mild abdominal distention with epigastric tenderness, no hepatosplenomegaly was noted. No signs of encephalopathy or asterixis were seen. Blood test showed hemoglobin 10.4 × 10 g/dL, white blood cell count of 7.7 × 103 cells/µL and platelet count of 190 × 103 cells/µL. Her prothrombin time and international normalized ratio (INR) were elevated at 1.4 and 14.3 s, respectively. Liver function test showed aspartate transaminase 140 U/L, alanine transaminase 29 U/L, alkaline phosphatase 332 U/L, total bilirubin 9.6 mg/dL (direct 7.4 mg/dL, indirect 2.2 mg/dL). Few hours after admission, she developed an episode of hematemesis with drop in hemoglobin to 7.7 g/dL. Emergent endoscopy showed a non-bleeding 2 cm prepyloric gastric antral ulcer (). Biopsy of the ulcer base was negative for malignancy or H. pylori.\nFollow-up endoscopy at an interval of 6 weeks showed a healing prepyloric antral ulcer with mild portal hypertensive gastropathy (). Patient had a repeat endoscopy at 4 months for persistent nausea and vomiting which again showed a healing antral ulcer. She continued to drink alcohol and was intermittently followed by her the primary care physician. She also reported daily NSAID use for abdominal pain and nausea. She had multiple emergency department (ED) visits for the same complaints and underwent repeat endoscopy which showed a duodenal ulcer (). She was managed with pantoprazole twice daily and was advised to avoid NSAIDs and alcohol. She also underwent extensive workup for recurrent nausea and vomiting which were all unremarkable. Systemic disorders including but not limited to neurological cause, adrenal, parathyroid and diabetes were also ruled out.\nShe again presented to the ED for worsening nausea and vomiting associated with upper abdominal pain. Endoscopy, now 7 years from the discovery of the initial lesion, showed a GDF. The prepyloric antral ulcer had fistulized into the duodenal bulb creating the appearance of a double pylorus (). Biopsy of the ulcer base was again negative for malignancy or H. pylori. H. pylori stool antigen and serum H. pylori antibody test were also negative. She was discharged on oral proton pump inhibitor and has been followed up with gastroenterology for management of Laennec’s cirrhosis. With more frequent outpatient follow up, alcohol abstinence and use of acid-suppression medication, she had gradual improvement in her symptoms in about 1 - 2 months.