CASE 1
EP, 34 Female
CC: Fever
1 month PTA Fever Tmax 38.9
Non-productive cough
Epigastric pain
Worked up - normal
2 weeks PTA Increased severity of epigastric pain,
with associated vomiting, no diarrhea
Persistence of fever
Admission

PMHx:
IgA nephropathy 2009 - on Prednisone
Bronchial asthma 2012
Persistent chronic epigastric pain
x~1year- s/p EGD 2013: Gastritis
(-) HPN, DM, PTB
FHx:
Unremarkable
PSHx:
Non-smoker
Non-alcoholic beverage drinker
Denies illicit drug use

PE:
Conscious, coherent, not in CP distress
BP 120/80 CR 90 RR 18 Temp 38.9C
Pink palpebral conjunctiva, anicteric sclerae
Supple neck, cervical lymphadenopathies
Symmetrical chest expansion, no retractions, clear breath sounds
Adynamic precordium, AB 5th ICS L MCL, no murmurs
Globular abdomen, NABS, soft, tenderness at the epigastric and
RUQ area, no organomegaly, no mass
Pulses full and equal, no edema
DRE: no mass, no melena

Course in the ward
• Managed as a case of fever of unknown
origin
• Laboratory work ups:
CBC Chest CT scan
Blood CS Whole abd CT scan
Typhidot Serum Galactomanan
2D echo Amylase, Lipase
Urinalysis

CBC:
HGB 10.2
HCT 0.31
WBC 16.83
NEUTRO 85.6
LYMPHO 4.6
MONO 8.6
PLT 385
Urinalysis:
Yellow
Clear
SG 1.020
PH 6.0
Protein +2
Glucose Neg
WBC 2/hpf
RBC 2/hpf
Epith cells 2/hpf
Bacteria 5/hpf
CC:
Na 134
K 4.8
Cl 97.0
Crea 176.8
Amylase 66
Lipase 18

• Blood CS: no growth
• Typhidot
– IgG, IgM:
Negative

Interpret whole abdominal CT scan

What is your impression?
What are your differential diagnoses?
What is your next diagnostic plan?
Interpret EGD

What is your impression?
Interpret colonoscopy

What would be your next diagnostic plan?
Interpret upper GI series

What is your final impression?
What would be your plan of management?

What is the ideal management in dealing with fistula?

• Colonic-duodenal fistulas are rare, and may be
secondary to benign or malignant conditions
• Most common lesion - carcinoma of the
transverse colon
Xenos E S, Halverson J D. Duodenocolic fistula: case report and review of the literature. J
Postgrad Med 1999;45:87

• Of the reported cases of benign duodenocolic
fistula, 30 have followed disease primarily in
the duodenum - peptic ulcer, diverticulum and
as a sequel to gastrectomy
• Colonic disease - regional enteritis, ulcerative
c olitis, appendicitis, diverticulosis coli and
typhoid fever accounted for 20

• Gallbladder - cholecystitis and biliary tract
surgery for 17
• The origin was uncertain in 23 cases-
developmental, tuberculosis, foreign body,
etc.
J. R. McQuaide. G. Naidoo. Benign Duodenocolic Fistula, A Report of 3 Cases.
South African Medical Journal. 1979.600-604

Clinical Presentation
• Diarrhea - occasionally bloody and often
intermittent
• Weight loss
• Upper abdominal colicky pain
• Vomiting or foul eructations

• Symptoms tend to be episodic, with short
exacerbations and long remissions.
• Emaciation follows, with electrolyte
imbalance
• Superimposed on these basic features may
be other signs and symptoms due to the
primary condition

Treatment
• Current therapeutic options include medical
treatment and surgical management.
• Spontaneous healing of fistulas without
treatment is rare.
• Various placebo-controlled clinical trials of
medical treatment have shown a fistula self-
closure rate of only 6% to 13%.

• For symptomatic internal fistulas, surgical
resection of the affected bowel segments was
required.
• Small fistulas can be occluded with fibrin glue
or clipping by endoscopy whereas in large
fistulas, endoscopic therapy with a detached
endoloop and hemoclips is an alternative
bridging method until final surgical repair.

• A review of the English literature showed only
sixty-three cases of CD with coloduodenal
fistula. Surgery remains the mainstay of
therapy.
Meng-Tzu Weng, Shu-Chen Wei, Yu-Wen Tien, I-Lun Shih, Jau-Min Wong. Crohn’s
Disease Complicated with Duodenocolic Fistula: A Case Report

• Case series have described the successful use
of cyanoacrylate glues for the endoscopic
treatment of refractory bile leaks, pancreatic
fistulae and a variety of other GI tract fistulae;
however, there are no controlled trials.
Seewald S. et.al. Endoscopic treatment of biliary leakage with n-butyl-2-cyanoacrylate.
Gastroint Endosc 2002; 56:916-9

• A recent randomized trial comparing fibrin
glue with observation only for Crohn’s patients
with anal fistulae found higher closure rates in
the glue patients (38% vs 16%, P Z.04)
• Numerous case series report achieving
prompt closure with the use of fibrin glue for
enterocutaneous fistulae, including persistent
gastrocutaneous fistulae after gastrostomy
tube removal.

• Fibrin glue has been used to close esophageal
perforations in case reports.
• A single case report exists with successful
closure of a duodenal perforation with fibrin
glue.

• A case report in which a covered colonic stent
was used successfully to close the fistula by
using an anooral guide wire (”body floss”
technique).
Shubhang Kulkarni, et.al. Covered Stent Placement for Duodenocolic Fistula: A
Novel Use of the ”Body Floss” Technique. Journal of Vascular and Interventional
Radiology.Pages 729–730, May 2011

End of first case

Case 2
EB, 38 Male
CC: Jaundice and
melena
7 years PTA: Jaundice
Local hospital:
SGPT = 177
SGOT = 151
ALP= 441
HBsAG = NR
UTZ:
• enlarged left liver lobe
• low normal sized right liver lobe
with several parenchymal
calcification
• left intrahepatic duct calculi
• Intrahepatic ducts are mildly
dilated
• 4.6x3.8 cm hyperechogenic focus
at region of porta hepatis
Hepatobiliary TB
TB-DOTS x 6months
Lost to follow-up

5 years PTA: Persistence of jaundice
Hematochezia
EGD: Unremarkable
Colonoscopy: Not consented
CT SCAN whole abdomen:
• enlarged left liver lobe
• atrophied right liver lobe with several
parenchymal calcifications
• segmental narrowing over D1-D3 and
sigmoid area
Treated with anti-koch’s for 6 months
but lost to follow up

2 days PTA: Melena 2x/day ~ 50ml per episode
Epigastric pain 8/10 no radiation to the back
No hematochezia
Still with jaundice
At the ER: Hematochezia ~400mL
BP 80/50 mmHg, CR 110/min
Admission

PPMHx:
(+) Hepatobiliary TB – treated x 6 months 2007
(-) HPN, DM, dyslipidemia, hepatitis
(-) renal disease
(-) allergies, asthma
(-) cancer, stroke, heart attack
(-) trauma and surgery
PSHx:
Non-smoker
Non-alcoholic beverage-drinker
Previous use of illicit drugs – stopped 4 years ago
FHx:
No liver disease, cancer, stroke, DM
(+) HPN

ROS:
(-) cough
(-) dyspnea, chest pain, palpitations
(-) constipation, diarrhea
(-) dysuria
PE:
Awake, alert, coherent
BP= 80/50, CR= 110/min, RR= 18 Temp= 37; BMI= 22
Pale palpebral conjunctiva, icteric sclera, no active dermatoses
Non-hyperemic PPW, supple neck, no cervical LAD
Symmetrical chest expansion, clear breath sounds
Adynamic precordium, AB 5th LICS MCL, (-) murmurs
Abdomen flabby, normoactive, soft, no masses and tenderness. liver
span 10 cm from MCL, traube’s space obliterated, no caput, no
spider angioma
Pulses poor and equal, no edema and cyanosis
DRE: red stool tactating finger

CBC: 6/27 7/4
HGB 86 66
HCT 269 197
WBC 7.9 10.8
NEUTROPHILS 64 80
LYMPHOCYTES 30 17
PLT 191 298
CC: 6/27 7/4
NA 134 135
K 3.8 3.9
BUN 5.8
CREA 122 88
6/27
PT INR
TB 5 mg/dl
DB 3 mg/dl
IB 1.1mg/dl
albumin 25.47
AST 114
ALT 113
ALP 620
HBsAg NR
Anti-HBS NR
Anti-HCV NR

What are your differential diagnoses?
What is your diagnosis?
What is your next diagnostic plan?
Interpret the endoscopy

What is your next diagnostic plan?
Interpret duodenoscopy

What is your diagnosis?
What is your next diagnostic plan?
Interpret CT angiogram

CT ANGIOGRAPHY
• Lobulated vascular structure within dilated CHD
• ( consider a vascular malformation or pseudoaneursym from a
branch of right hepatic artery)
• Mildly dilated IHD, CBD, distended GB & cystic duct
secondary to iso to hyperdense foci in CHD & CBD
(most likely blood clots)
• Contracted right liver lobe and enlarged left liver lobe
with chronic liver parenchymal disease and
calcifications
• Distented GB with thickened walls and soft calculi
• Tiny CHD calculus
• Prominent spleen
• Paraesopahgeal,perigastric,peripancreatuc and
perisplenic varices

HEPATIC ARTERY ANEURSYM
• 12% of visceral aneurysm
• 20% Intrahepatic
• 30% right hepatic artery – 2nd to common
hepatic artery
• Tuberculosis incidence?
Abbas J Vasc Surg 2003
Taylor Postgrad Med J 1986

TUBERCULOSIS
• Most – saccular, pseudoaneurysm and rapid
growth
• Mechanism
– Erosion of vessel wall by contiguous focus of TB
– Direct seeding of the intima, adventitia or media
via vasa vasorum
TSURUTANI Int. Med 2000
Husen annals Saudi Med 1997

HEPATIC ARTERY ANEURSYM
• Quincke’s triad of hemobilia (jaundice, right
upper quadrant pain, bleeding) – 1/3 of cases
• Risk of rupture 14%
• Rupture biliary tree 41%
• Mortality – 40%
• Angiography – gold standard
Trauman – Mays Surg Clinics of N.A. 1977
Harlaftis Amer Journal of Surg 1977
Singh world Journal of Gastroenterology 2006

HEPATIC ARTERY ANEURSYM - TREATMENT
• Endovascular technique (preferred) (Lumsden 1996)
– Coils (large feeding vessel), particular embolics, glue, or
Onyx )
– Complications (Abbas 2003)
• Short term – hepatic ischemia, abcess and cholecystitis
• Long term- recanalization
• Surgery
– risk of hepatic necrosis – small
– 26 collaterals liver (Michles 1966)
– Ligation, excision, endoaneurysmorrhaphy, wrapping.
Wiring, hepatic lobectomy, suture of aneurysm to liver
(Ariyan 1975)
– High risk post operative complications (Ikeda 2010)

End of second case

NW, 47 Male
7 days: Epigastric pain
3 days: Fever
Anorexia
Malaise
2 days: Melena
Dizziness
SEHx:
Non-smoker
1 bottle of gin daily x 10 years
Marijuana use
Garbage collector, fruit sorter
Case 3
CC: Melena
PPMHx:
(-) HPN, DM, TB, CVA, CAD
(-) previous surgery
(-) intake of NSAID, ASA, steroid

Awake, coherent, cooperative, weak-looking, not in CP distress
100/60, 100-110/min, 37-38.6’C
Pale palpebral conjunctivae, anicteric sclerae
Clear breath sounds, no spider angioma
Flat abdomen, NABS,, direct tenderness at the epigastric area,
hepatomegaly 14cm, (+) obliterated traube’s space, no ascites, no
caput medusa, no spider angioma
Good sphincteric tone, no mass, melena
CBC
Hgb 62 g/L
Hct 0.190
WBC 15.4 x109/L
Neutro 84%
Lympho 12%
Mono 4%
Platelets 401
CC
Crea 63umol/L
BUN 6.7umol/L
Na 132
K 3.3

What is your impression?
What is your next diagnostic plan?
What are your differential diagnoses?
Interpret endoscopy

During endoscopy, what would you do next?

Would you revise your impression?
What would be your next diagnostic examination?

What is your final impression?
What is your next diagnostic examination?

Endoscopic drainage

Ultrasound-guided aspiration of the right liver lobe abscess
How would you manage the right liver lobe abscess?

Gastric ulcer perforating to liver Pyogenic liver abscess penetrating
to stomach
incidenc
e
6 case reports 3 case reports
presenta
tion
Melena +/- epigastric pain, then
fever, +/- jaundice
Fever, +/- jaundice, +/- epigastric
pain, then melena
Diagnost
ics
Chronic looking ulcer Multiple ulcers
Treatme
nt
Surgical medical
Spontaneous fistulization o
S. Leite, A. P. Silva, et al.
Unusual cases and technica
Liver Abscess Complicated
Eun-Sun Kim, et al
Journal of gastroenterology
Hepatogastric fistula: a rare
Gandham VS, Pottakkat B, P
BMJ Case Rep.2014 Jul 17;2
micking
. Caletti
penetrating
subcapsular
g into the liver.
y
0

Follow-up EGD
before after

End of third case

Post-ERC