Hospital: H.U. Puerta de Hierro.
Aut@r o Autores: M. Reyero Lafuente, M. Collado Torres, M. Cea Soriano, P. García Benedito, E. Van Den Brule Rodríguez De Medina, A. Alcolado Jaramillo.
A 73-year-old man came to the emergency department with acute upper abdominal pain and hypotension. Without delay, an angiographic CT was performed with the suspicion of an acute aortic syndrome. No signs of acute aortic pathology were found but peripancreatic tail and body fat stranding. A large ill-defined defect on the lesser curvature and posterior wall of the stomach with diffuse gastric wall thickening and some enlarged lymph nodes in the gastrohepatic ligament were also found. We determined that a gastric ulcer had penetrated the pancreas with no data of active bleeding. Subsequently, the patient´s clinical information and laboratory tests were obtained, remarking: hemoglobin: 6.2 g/dL, C-reactive protein: 39.9 mg/dL and loss of appetite for months. A preferent endoscopy was performed and confirmed the presence of a 4cm ulcer in the wall of the stomach viewing the pancreas at the end of it. Histopathology of ulcer borders ruled out malignancy. Taking into account the few possibilities of responding to medical treatment, it was decided to treat the ulcer by surgery: subtotal-gastrectomy with gastrojejunostomy. The surgical findings correlate with those of previous endoscopy and CT. Histopathology of intraoperative biopsy of lymph nodes also ruled out malignancy.
The gastroduodenal ulcer is a very prevalent entity with diverse etiologies. The most serious complications are hemorrhage, perforation, penetration, and gastric outlet obstruction. Regarding ulcer penetrating the wall of the stomach, if adhesions prevent leakage into the peritoneal cavity, free penetration is avoided and confined perforation occurs. It is mandatory to look for data of active bleeding since the ulcer could erode local vessels. Pain may be very intense, referred to sites other than the abdomen (usually the back and it can be confused with other pathologies), and modified by body position. CT is the imaging technique of choice in the emergency setting. When therapy doesn't result in healing, surgery is required.
Ulcer gastric penetration is a very rare entity nowadays that must be taken into account in the differential diagnosis of acute abdominal pain in unstable patients. CT has a fundamental role in the emergency setting to determine a possible cause and allows early management. Ulcer gastric penetration is rare because the diagnosis of PUD is usually achieved earlier, preventing these complications from occurring and effective conservative treatment is available.
- Shibukawa N., Ouchi S., Wakamatsu S., Wakahara Y., Tatsumi N., Kaneko A. A Rare Case of Gastric Ulcer Penetrating the Pancreas that was Successfully Managed by Conservative Therapy. Intern Med, 2017, 56: 2277-2279 - Norris JR, Haubrich WS: The incidence