Introduction

Enterohepatic fistulas are rare complications of pyogenic liver abscesses, typically involving the stomach, colon, or duodenum [1,2]. Prompt identification may be challenging, as symptoms are often nonspecific. Esophagogastroduodenoscopy (EGD) may reveal unexpected fistulous tracts, while contrast-enhanced CT remains the gold standard for detailed characterization [3,4]. No standardized management guidelines exist; conservative drainage may allow spontaneous closure, though surgery is often required [3].

Methods

A 76-year-old woman presented to the emergency department with abdominal pain, epigastric pain, fever, and coffee-ground vomiting.       Given the suspicion of upper gastrointestinal bleeding, an urgent EGD was performed. The examination revealed an orifice with inflamed margins in the duodenal bulb, exuding purulent material—highly suggestive of a fistulous tract.     Based on these findings, a contrast-enhanced CT scan was promptly obtained, demonstrating a 42 × 30 mm abscess in segment V of the liver, containing air–fluid levels and extending toward the gallbladder bed and duodenum, confirming a hepato-duodenal fistula.

Results

Ultrasound-guided percutaneous drainage was performed and intravenous piperacillin/tazobactam was initiated. Despite a significative clinical improvement, persistence of the fistulous tract on follow-up imaging required surgical intervention. Postoperatively, the patient showed rapid clinical and biochemical improvement, and a CT scan confirmed complete resolution.

Conclusions

This case describes the endoscopic detection of a rare hepato-duodenal fistula secondary to a pyogenic liver abscess. The initial EGD—performed for suspected upper GI bleeding—proved crucial in early detection of the fistulous tract and guided subsequent imaging and therapy.