PMC8357508_01
Preoperative CT scan shows mild distention of the gallbladder with gallstones and adjacent inflammatory stranding extending to the first and second portion of the duodenum.
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Computed tomography (CT) of the abdomen with intravenous contrast showed a mildly distended gallbladder with gallstones, adjacent inflammatory changes extending to the first and second portions of the duodenum (D1 and D2) with a small amount of anterior perihepatic fluid, without additional free fluid or free air identified (Figure 1).
Depiction of Endoscopic Ultrasound-Directed Transgastric ERCP (EDGE procedure). Image provided by Dr. Prashant Kedia.
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Given the patient's RYGB anatomy, the gastric remnant was successfully accessed via endoscopic ultrasound-directed transgastric ERCP (EGDE procedure), with a 20 mm x 10 mm lumen-apposing metal Axios stent (Figure 2).
EDG shows a large fibrotic, chronic-appearing, penetrating duodenal bulb ulcer with fistulous tract in communication with the surgical drain.
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The gastrojejunal anastomosis was found to be widely patent and access to the biliopancreatic limb revealed a 2 cm deep, chronic-appearing, penetrating ulcer in the posterior duodenal bulb (Figure 3).