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Special Feature
June 16, 2008

Image of the Month—Quiz Case

Author Affiliations

Author Affiliations:Departments of Surgery, The Jikei University School of Medicine, Tokyo (Drs Iida, Hanyu, and Yanaga), and Sasaki Private Hospital, Saitama (Drs Akita and Sasaki), Japan.




Copyright 2008 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.2008

Arch Surg. 2008;143(6):609. doi:10.1001/archsurg.143.6.609

A 62-year-old man was admitted to the hospital with epigastric pain, nausea, anorexia, and abdominal distention. He had a history of duodenal ulcer with pyloric stenosis 10 years earlier and recent multiple gastric ulcers mainly in the gastric angle. The findings of a physical examination revealed anemia, emaciation, and epigastric tenderness without peritoneal signs. Peripheral blood cell counts and biochemical test results showed anemia (hemoglobin level, 10.9 g/dL [to convert to grams per liter, multiply by 10.0]), nutritional impairment (serum total protein level, 5.7 g/dL [to convert to grams per liter, multiply by 10.0]; albumin level, 3.1 g/dL [to convert to grams per liter, multiply by 10.0]; and total cholesterol level, 112 mg/dL [to convert to millimoles per liter, multiply by 0.0259]), and mild inflammation (C-reactive protein level, 18.1 mg/L [to convert to nanomoles per liter, multiply by 9.524]). Gastrointestinal fiberscopy (Figure 1) and barium enema (Figure 2) were performed.

Figure 1.
Image not available

Gastrointestinal endoscopy indicated a giant gastric ulcer at the gastric angle. At the bottom of the ulcer, what appears as the intestine with 2 openings (arrows) was identified.

Figure 2.
Image not available

Barium enema showed backward flow of barium from the transverse colon into the stomach (arrows).

What Is the Diagnosis?

A. Large peptic ulcer

B. Gastric adenocarcinoma type 2

C. Gastrocolic fistula associated with a gastric ulcer

D. Gastric submucosal tumor