An 85-year-old female with a past medical history of hypertension was admitted to A&E after experiencing a sudden episode of loss of consciousness (LOC), haematemesis and melaena. On arrival, she displayed symptoms of shock including profuse sweating and hypotension (BP 57/42 mmHg), and required 2L of oxygen to adequately maintain her target oxygen saturation. Her heart rate is 83bpm. She had no history of abdominal surgery, gallstones or allergies, however, additional information on her medical history was challenging to obtain due to acute confusion. She did report experiencing epigastric pain over the past week and mentioned regular use of non-steroidal anti-inflammatory drugs (NSAIDs) for her back pain.

Physical examination revealed generalised abdominal tenderness. Blood tests showed she had metabolic acidosis (pH 7.27) and anaemia (Hb of 77 g/L). After transfusing the patient with 2 units of red blood cells, 1L of crystalloid solution, and the initiation of noradrenaline support (administered at a rate of 4.8 ml/hr), her condition stabilised. A CT scan of the abdomen was performed, revealing a choledocho-duodenal fistula (CDF) with concomitant cholangitis as well as proximal duodenitis and evidence of blood in the stomach. Notably, no gallstones were detected on CT.

A nasogastric (NG) tube was placed to remove the blood in her stomach after which an oesophagogastroduodenoscopy (OGD) was then performed, which detected an actively bleeding Forrest 1A posterior duodenal ulcer. The gastro-duodenal artery was found to be the source of the bleed and this was managed endoscopically using clipping.

Following the procedure, the patient was transferred to the ICU where her condition remained stable. Gradual withdrawal of the noradrenaline support was initiated, and no further blood transfusions were necessary. The patient underwent further testing and was found to have a gastric infection, for which she was treated with antibiotics. After a stay of 9 days in the hospital, the patient was discharged and had no further issues on follow-up.

From left to right:

1) CT abdomen showing (A) the presence of blood in the stomach, aerobilia (yellow arrow) and (B) inflammation of the first part of duodenum (red arrow)

2) Endoscopic picture showing the 1A Forrest duodenal ulcer with the presence of a choledocho-duodenal fistula (CDF) and an active bleeding of the gastro-duodenal artery around the fistula (B).

3) Endoscopic picture showing the 1A forrest duodenal ulcer treated with an over the scope clip.

4) Picture adapted from the article of Ikeda et al., illustrating the two types of CDF according to the location of the fistula

Source: https://doi.org/10.3389/fsurg.2023.1206828

Case Summary & Questions written by Dr Ahmed Kazie

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