Gastric Cancer Forming a Fistula Into the Liver

What happened, in summary

A 73-year-old woman was admitted with fever and right flank pain. Initial testing suggested a urinary infection, but blood cultures grew Streptococcus constellatus and imaging showed a liver lesion that enlarged into a 7.5 cm abscess. She later developed severe vomiting of blood, her hemoglobin fell to 55 g/L, and she required intensive care and 8 units of red blood cells. Urgent endoscopy found a large ulcerated mass in the gastric antrum, and biopsy showed adenocarcinoma.

The stomach cancer had directly formed a fistula into the liver, causing the abscess, sepsis, and major bleeding. A drainage catheter was placed in the abscess. She then chose surgical exploration and underwent en bloc subtotal gastrectomy with removal of the left lateral liver section, excision of a peripancreatic lymph node, and Billroth II reconstruction. Pathology showed completely resected pT4bN2 poorly differentiated gastric adenocarcinoma with focal lymphovascular invasion; 5 of 24 lymph nodes were positive. She recovered from surgery, apart from a superficial wound infection, and went home after 10 days.

One month later, adjuvant therapy was not started because her performance status was 2 and she did not want treatment that might reduce her quality of life. Four months after surgery, local recurrence and new deposits in the caudate liver developed. She declined further anticancer treatment. Two months later, hepatic and pulmonary metastases led to admission under palliative care, and she died peacefully in hospital.