Portal tracts on a duodenal biopsy: Hepatic penetration of a duodenal ulcer
Background: Liver penetration is a rare but serious complication of peptic ulcer
disease. There are less than 15 reports in the literature.
Body: A 88 year old fully independent woman presented to the Canberra hospital
with a 3 day history of epigastric pain radiating to the back, melena and
progressive shortness of breath. She was using piroxicam intermittently over a
period of more than 20 years for osteoarthritis. She was also a current smoker.
On arrival to the hospital, she was profoundly anaemic (haemoglobin 38 g/l),
hypotensive and tachcardic with metabolic acidosis and a raised urea of 32.1
mmol/l and creatinine of 134 micromol/l. Liver function tests and serum lipase
were normal. Abdominal examination revealed epigastric tenderness but no
guarding or rigidity. Bowel sounds were present. Rest of the examination was
unremarkable. After adequate resuscitation and blood transfusion, she
underwent an abdominal CT. Oral and IV contrast were deferred due to renal
impairment. The abdominal CT showed several gas locules in the region of the
porta hepatis raising the suspicion of a perforated hollow viscus. However, the
abdomen remained soft and her vital signs continued to be stable. In
consultation with the surgeons, she was managed conservatively. Gastroscopy
the next day revealed a giant ulcer (Forest III) in the duodenal cap. In view of its
size, biopsies were obtained from the ulcer base to exclude malignancy.
Histologic examination demonstrated a duodenal ulcer in continuity with the
hepatic parenchyma. Helicobacter pylori was not identified. She was treated with
pantoprazole and repeat gastroscopy 6 weeks later confirmed healing of the
duodenal ulcer.
Discussion: Peptic ulcers usually penetrate into the pancreas, gastrohepatic
omentum or biliary tract. Penetration of a peptic ulcer into the liver is extremely
rare. The majority of these cases have involved ulcers arising from the stomach
(usually antral or stomal). In rare cases, the ulcers may originate from the
duodenum, with most being located within the duodenal cap. Many of the
reported cases have needed surgery and/or endoscopic dilatation to treat
duodenal stenosis. This patient was fortunate to escape an operation. Diagnosis
is not always possible pre-operatively by imaging or even endoscopically (as in
this case) and may become apparent only by histologic evaluation of duodenal
biopies. In cases where histology is available, non-specific inflammatory changes
are reported in the liver parenchyma. Rarely, the presentation can be insidious
with patients presenting with a liver mass that can pose diagnostic problems.
Conclusion: Endoscopists should consider hepatic penetration of a duodenal
ulcer, particularly in cases with ill-defined regional findings on an abdominal CT.