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CASE REPORT
Year : 2020  |  Volume : 23  |  Issue : 4  |  Page : 586-588

Obstructive jaundice caused by ulcerative duodenal stenosis: A case report


1 Department of Gastroenterology, Pukou District Central Hospital, Pukou Branch of Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
2 Institute of Digestive Endoscopy and Medical Center for Digestive Diseases, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China

Date of Submission24-Oct-2018
Date of Acceptance26-Dec-2019
Date of Web Publication4-Apr-2020

Correspondence Address:
Dr. Z Liu
Institute of Digestive Endoscopy and Medical Center for Digestive Diseases, The Second Affiliated Hospital of Nanjing Medical University, 121 Jiang Jia Yuan, Nanjing 210011
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_537_18

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   Abstract 


A peptic ulcer is a rare cause of distal common bile duct stricture, Obstructive jaundice as a complication of ulcerative duodenal stenosis is quite difficult to differentiate from malignant disease, especially in those in which esophagogastroduodenoscopy examination does not reveal an ulcer. In this case report, a 61-year-old male suffered from right upper quadrant pain, chills and fever caused by duodenal and distal common bile duct stenosis originating from ulcer and was treated surgically.

Keywords: Cholangitis, duodenal ulcer, obstruction jaundice, stenosis


How to cite this article:
Chen L, Zhu X, Wei L, Liu Z. Obstructive jaundice caused by ulcerative duodenal stenosis: A case report. Niger J Clin Pract 2020;23:586-8

How to cite this URL:
Chen L, Zhu X, Wei L, Liu Z. Obstructive jaundice caused by ulcerative duodenal stenosis: A case report. Niger J Clin Pract [serial online] 2020 [cited 2020 Sep 28];23:586-8. Available from: http://www.njcponline.com/text.asp?2020/23/4/586/281929




   Introduction Top


Obstructive jaundice is caused by an interruption to the drainage of the conjugated bilirubin in the biliary system. The most common causes are choledocholithiasis and malignant conditions such as pancreatic head carcinoma.[1],[2] Other causes include biliary atresia, cholangiocarcinoma, pancreatitis, and pancreatic pseudocysts.[3] Duodenal ulcer is a rare cause of obstructive jaundice especially in recent decades. Herein, we report a 61-year-old male who consulted our department for right upper quadrant pain, chills and fever caused by duodenal and distal common bile duct stenosis, and was treated by surgery. we felt it was important to draw attention to this rare complication of peptic ulcer disease.


   Case Report Top


A 61-year-old man was admitted to our department on account of recurring right upper quadrant pain for more than ten years, and with exacerbation of pain along with chills and high fever the day before admission. He had peptic ulcer disease without H. Pylori infection and normal level of gastrin. He received standard proton pump inhibitor (PPI) therapy. Fever, jaundice and abdominal tenderness in the right upper quadrant were revealed on the physical examination. Laboratory values for serum glutamic-oxaloacetic transaminase (SGOT) and serum glutamic-pyruvic transaminase (SGPT) showed slight elevations of 49 U/L and 117 U/L, respectively. Serum bilirubin was 60.2 umol/L, alkaline phosphatase 179 U/L, gamma-GT 311 U/L and the carbohydrate antigen 19–9 was 354.1 U/ml.

An enhanced computed tomography (CT) scan showed a 2.6-cm-diameter low-density mass in the left lobe of liver [Figure 1]. Both the bile duct and pancreatic duct were dilated, a low-density area was detected within the pancreatic neck and there was no evidence of lymphadenectasis [Figure 1]. At first, we performed an Endoscopic Retrograde Cholangiopancreatography (ERCP) in order to relieve the obstruction of bile duct, but severe stenosis (0.5-cm-diameter) at the junction of the duodenal bulb and the descending part prevented the duodenoscope from passing and prevented visualization of the papilla, even after balloon dilatation of the stricture [Figure 2]. Magnetic resonance cholangiopancreatography (MRCP) showed stenosis of the distal common bile duct with dilatation of duct. The pancreatic duct was also dilated, strictures were seen at the junction of the duodenal bulb and the descending part as well as the antrum [Figure 3]. Based on these findings, it was strongly suspected that the patient might have malignant disease such as duodenal ampulla cancer.
Figure 1: Enhanced computed tomography (CT) scan showing (a) a low-density mass in the left lobe of the liver and dilated common bile duct. (b) intra-hepatic bile duct dilation and pneumonia

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Figure 2: Endoscopic image showing balloon dilation of the duodenal stenosis. (a) Severe stenosis (0.5-cm-diameter) at the junction of the duodenal bulb and the descending part preventing the duodenoscope from passing through. (b). Non-visualization of duodenal papilla during the gastroscope examination after balloon dilation

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Figure 3: Magnetic resonance cholangiopancreatography (MRCP) showing multiple stenoses. (a) stenosis of the distal common bile duct. (b) strictures at the junction of the duodenal bulb and the descending part

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During open surgery, serious adhesions were found among the omentum majus, abdominal wall, cholecyst, duodenum and part of the liver. The tissues around the pancreatic head and papilla were thickened. Taken the obstruction condition and potential risk of malignant stricture into consideration, a pancreaticoduodenectomy (PD) was thus performed. After the pancreaticoduodenectomy, Gastrojejunostomy, pancreatojejunostomy and hepaticojejunostomy were performed. At histological examination, the stenosing duodenal lesion was considered a benign ulcer, with low-grade dysplasia, was detected around its margin [Figure 4]. The patient's postoperative course was uneventful. He continues to be regularly followed up for nearly four years on an outpatient basis and has had no recurrence of symptoms.
Figure 4: Histological section showing ulcer at the junction of duodenal bulb and the second part and low.grade dysplasia was detected around the ulcer

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   Discussion Top


The duodenal ulcer can give rise to rare complications, such as choledochoduodenal fistula,[4] choledochopancreatoduodenal fistula,[5] and also to biliary obstruction.[6],[7] This case is a patient suffering from abdominal pain, chills and fever caused by ulcerative duodenal and distal common bile duct stenosis. To our knowledge, there are case reports in the English kinds of literature referring to obstructive jaundice caused by ulcerative strictures in the 20th century,[7],[8],[9],[10] but rather few cases in the last decade.

There was a similar case reported by Hidalgo in 2010, in which biliary obstruction was considered due to pancreatic cancer preoperatively but which proved to be a complication of chronic duodenal ulcer.[6] In general, Esophagogastroduodenoscopy plays an important role in the diagnosis and management of peptic ulcer and stenosis, but we didn't identify any ulcerative lesion in this patient at endoscopy, and the non-visualization of the papilla made ERCP impossible. According to the diagnostic imaging studies, the patient was strongly suspected of having malignant disease.

In this case, localized perforation or penetration and cicatricial contraction were considered to be responsible for stenosis of the common bile duct. whereas penetrating duodenal ulcer may be another mechanism of the obstruction of the common bile duct.

Surgical interventions were carried out in most patients previously reported.[6],[7],[9],[10] With the development of endoscopic treatment, Balloon Dilatation, Savary bougie dilatation, and stent were widely used for gastrointestinal tract strictures. But we chose surgical therapy for the patient due to the difficulty in performing endoscopic interventions and the suspicion of malignancy.

In conclusion, we report an interesting case of obstructive jaundice and cholangitis caused by stenosis of the common bile duct from duodenal ulceration. This is an extremely rare complication of duodenal ulcers.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Bekele Z, Yifru A. Obstructive jaundice in adult Ethiopians in a referral hospital. Ethiop Med J 2000;38:267-75.  Back to cited text no. 1
    
2.
Gracanin AG, Kujundzic M, Petrovecki M, Romic Z, Rahelic D. Etiology and epidemiology of obstructive jaundice in Continental Croatia. Coll Antropol 2013;37:131-3.  Back to cited text no. 2
    
3.
White TT. Obstructive biliary tract disease. West J Med 1982;136:484-504.  Back to cited text no. 3
    
4.
Naga M, Mogawer MS. Choledochoduodenal fistula: A rare sequel of duodenal ulcer. Endoscopy 1991;23:307-8.  Back to cited text no. 4
    
5.
Aitken RJ, Bornman PC, Dent DM. Choledochopancreatoduodenal fistula caused by duodenal ulceration. A case report. S Afr Med J 1986;69:707-8.  Back to cited text no. 5
    
6.
Hidalgo L, Repiso A, Romero M, Navajas J, Sanchez-Simon R, Gomez-Rodriguez R, et al. Obstructive jaundice as a complication of a peptic duodenal ulcer mimicking pancreatic cancer. Endoscopy 2010;42(Suppl 2):E294-5.  Back to cited text no. 6
    
7.
Fuller JW, Christensen JA, Sherman RT. Common bile duct obstruction secondary to peptic ulcer. Am Surg 1975;41:640-2.  Back to cited text no. 7
    
8.
Van Steenbergen W, Ponette E, Marchal G, Fevery J, De Groote J. Distal common bile duct stenosis secondary to benign duodenal ulceration: Report of a case. Gastrointest Radiol 1990;15:215-7.  Back to cited text no. 8
    
9.
Glick S. Benign non-traumatic stricture of the common bile-duct owing to penetrating duodenal ulcer. Br J Surg 1971;58:918-20.  Back to cited text no. 9
    
10.
NEIMAN JH. Obstructive jaundice caused by duodenal ulcer. J Am Med Assoc 1953;152:141.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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