LAUSR

A 3-year-old boy was referred to our endoscopy unit for esophagogastroduodenoscopy and colonoscopy after complains of malena for 2 days. He was being treated for his febrile illness for last 10 days. His hemoglobin had dropped down to 4 mg/dL and had subsequently received blood transfusion. Esophagogastroduodenoscopy revealed a large deep ulcer along the lesser curvature of stomach with huge adherent blood clot with no active bleed (Fig. 1a). Such a deep ulcer at an unusual location with likelihood of impending perforation prompted us for a requisition of contrast enhanced CT abdomenwith oral contrast. CT revealed liver abscess in both right (segments V and VIII) and left lobes of liver (with air foci). Right lobe abscess was seen rupturing into subphrenic region and left one into stomach along lesser curvature (Fig. 1b). Because of uncontrolled sepsis, percutaneous drain (PCD) drain was placed in right lobe abscess to facilitate drainage. Pus culture showed Escherichia coli, and appropriate antibiotics were started. Nasojejunal tube was placed to facilitate feeding and spontaneous closure of hepatogastric fistula (HGF). However, 4 weeks later on reevaluation, the fistula persisted. Hence, surgical closure of defect with omental patch was performed with favorable outcome. Hepatogastric fistula is an extremely rare internal fistula, which develops as a complication of rupture of liver abscess or tumor into the stomach. Although cases of HGF have been reported in the literature, upper gastrointestinal bleed in a child due to HGF, leading to diagnosis of liver abscess is not described yet. Previous reports have discussed liver abscess (amoebic/ pyogenic) or hepatocellular carcinoma in adults that spontaneously or after intervention led to HGF. Both medical and surgical management of such fistula has been described, depending on the individual case characteristics with favorable outcome. Upper gastrointestinal bleed due to an unexplained deep ulcer at an unusual location should alert the clinicians to look for its underlying cause. High index of suspicion, early recognition, and avoidance of prolonged air insufflation during endoscopy are key to diagnosis and management of this rare entity.