S6110 A Rare Case of Hepatoduodenal Fistula Secondary to Duodenal Ulcer Disease

Introduction: Hepatoduodenal fistulas are rare connections between the liver and duodenum, typically arising from liver abscesses, tumors, gastric perforation, or iatrogenic causes such as transarterial chemoembolization. We present a case of a hepatoduodenal fistula secondary to a peptic ulcer, presenting with severe gastrointestinal bleeding and a complicated clinical course. Case Description/Methods: A 76-year-old man with a history of atrial fibrillation and CVA on clopidogrel, and multiple comorbidities was transferred from an outside facility after presenting with general malaise. He had been previously diagnosed with a presumed contained perforated duodenal ulcer (without endoscopy) and discharged on oral PPI therapy. He subsequently returned with large-volume hematochezia, syncope, and hemoglobin of 5.4 g/dL, along with an elevated BUN-to-creatinine ratio and epigastric pain. He had a recent history of excessive nonsteroidal anti-inflammatory drug use. On physical exam he had mild diffuse abdominal tenderness and melena on rectal examination. Initial abdominal computed tomography revealed a suspected contained duodenal perforation, necrotic hepatic mass, and possible duodeno-hepatic fistula at the porta hepatis. Esophagogastroduodenoscopy showed a large duodenal clot, a perforated ulcer with a fistula into hepatic parenchyma, multiple adherent clots, and 2 non-bleeding angiectasias. Given the ulcer size and fistula, surgery was advised. Exploratory laparotomy confirmed duodenal perforation into a bleeding hepatic cyst. Surgical procedures included gastroplasty, pyloric exclusion, Roux-en-Y gastrojejunostomy, marsupialization of the cyst, fistula takedown, Graham patch, omental pedicle flap, and open cholecystectomy. Postoperative computed tomography showed a worsening gallbladder fossa collection and high bilious drain output, indicating a duodenal stump leak. After failed transhepatic cholangiography, IR performed biliary diversion. The patient improved on antibiotics and was discharged. Discussion: Gastrointestinal perforations are a significant cause of morbidity and mortality, usually presenting with bleeding. Fistulization to adjacent organs may contain bleeding and delay diagnosis. Hepatoduodenal fistulas often cause nonspecific symptoms—abdominal pain, fever, jaundice—or are found incidentally. Complications include biliary sepsis, infection, or gastrointestinal bleeding. Diagnosis typically involves imaging (computed tomography, magnetic resonance cholangiopancreatography, cholangiography) and sometimes endoscopy. Management varies by case, depending on stability and complications, and may be conservative, endoscopic, or surgical.