Pus from the pylorus: an unusual endoscopic finding suggestive of periduodenal abscess.

A 32−year−old man in whom a perforated duodenal ulcer had been surgically closed with laparotomy 3 weeks previously pre− sented to our emergency department with symptoms of persistent epigastralgia and fever. At esophagogastroduodenoscopy, abundant whitish pus was noted stream− ing from the pylorus into the gastric an− trum (Figure 1). The source of the pus was a large duodenal ulcer in the de− formed duodenal bulb, where surgical su− tures remained (Figure 2). A reformatted computed−tomographic image identified a fistula (Figure 3) between a subphrenic abscess and the duodenal bulb, account− ing for the origin of the pus stream in the stomach. The patient received percuta− neous drainage of the subphrenic abscess, parenteral antibiotics, and proton−pump inhibitors. Therapy to eradicate Helico− bacter pylori was prescribed. He made an uneventful recovery without a repeat op− eration and remained well during a 6− month follow−up period.