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 male 59-year-old patient was admitted to the Dr. Soetomo General Hospital with hematemesis and melena. The patient complained of hematemesis for 6 h before admission. He vomited three times with an amount of 200–300 mL and had lower abdominal pain. Defecate black liquid twice since 6 h before admission with a very bad smell. The patient complained of dizziness accompanied by nausea and had no appetite since 5 days. There had been shortness of breath when performing heavy activity, reduced when resting and absence of fever.\nThe patient had a history of diabetes mellitus since 3 years. He was under insulin and oral medication but irregularly. History of hypertension, heart, lung, and kidney diseases was denied. There was a history of consuming medicinal herbs for myalgia. The patient consumed it every day. He felt weak when he did not drink. He used this drug for the past 5 months. Psycho-social history: he works as a construction worker and is smoking three packs a day since youth.\nOn physical examination, it was found with compos mentis GCS 456 that his blood pressure was 125/75 mm Hg, heart rate was 96 ×/min regular, strong pulse, adequate content, respiratory rate was 20 ×/min, the axillary temperature was 36.5°C, and SpO2 was 99% of free air. The examination of head and neck conjunctiva anemic was present, no jaundice, no cyanosis, no dyspnea, no enlarged lymph nodes, jugular venous pressure does not increase. The thorax was normal, the abdomen appeared flat and there was no palpable mass, liver and spleen enlargement were not palpable, he had normal bowel sounds, and abdominal pain in the umbilical region. Extremities were warm, dry acral, capillary refill time <2 s. No edema was found on both legs.\nLaboratory tests showed that his Hb was 8.3 g/dL, hematocrit was 23.6%, MCV 78.1; MCH 27.5; MCHC 35.2; platelets were 356,000 mm3, leukocytes were 14,369 mm3, neutrophils were 79.1%, lymphocytes were 14.5%, sodium was 132 mmol/L, potassium was 4.4 mmol/L, chloride was 106 mmol/L, HbA1C was 11.2%, random blood sugar was 202 mg/dL, SGOT was 16 U/L, SGPT was 27 U/L, blood urea nitrogen (BUN) was 28 mg/dL, serum creatinine was 1.14 mg/dL, and albumin was 3 g/dL. The examination of chest radiograph showed normal heart and lungs.\nThe patient was treated with a B1 soft diet 2,100 kcal/day, infusion of NaCl 0.9% 1,500 mL in 24 h i.v., injection of omeprazole 40 mg every 8 h i.v., sucralfat syrup 15 mL every 8 h orally, novorapid injection 4 units every 8 h sc ac 15 min, transfusion of packed red cells (PRC) 1 bag/day until Hb >10 g/dL, metoclopramide 10 mg every 8 h i.v., amlodipin 10 mg every 24 h orally, lactulac syrup 15 mL every 8 h orally, Ceftriaxon 1 g every 12 h i.v., and paracetamol 500 mg every 8 h orally.\nThe patient had been given PRC transfusion until Hb reached 10.3 g/dL, and the upper gastrointestinal EGD showed that the cause of bleeding to this patient was a gastric ulcer which was suspected and caused by consumption of medicinal herbs. At EGD, double pylorus was accompanied by giant white ulcer with a partially covered in clotting without any sign of active bleeding. It could be concluded that there was a double pylorus with giant ulcer, Forrest IIb (Fig. ).\nAfter 1 week of treatment at Dr. Soetomo General Hospital, the patient's complaints were improved and he had no nausea nor vomiting, there were no hematemesis and melena, and his appetite was improved. The patient was discharged from hospital. Planning therapy was B1 soft diet 2,100 kcal/day, omeprazole 20 mg every 12 h per oral, sucralfat syrup 15 mL every 8 h orally, novorapid injection 4 units every 8 h sc ac 15 min, amlodipin 10 mg every 24 h orally. Biopsy revealed chronic inactive gastritis, and no H. pylori was detected. The patient underwent checkup at the Gastroenterology department after 1 week of hospital discharge with complaints of decreased appetite, abdominal pain, and no nausea and received sucralfate syrup and lansoprazole orally.