Image of the Month—Quiz Case

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. 

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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. 

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

A. Large peptic ulcer

B. Gastric adenocarcinoma type 2

C. Gastrocolic fistula associated with a gastric ulcer

D. Gastric submucosal tumor

Answer