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Clinical Images

A Peek-a-Boo Liver

Authors: Rashmi Advani, MD1 and Benjamin T. Galen, M.D2


1Albert Einstein College of Medicine and Montefiore Medical Center, Department of Internal Medicine, Bronx, NY USA


2 Albert Einstein College of Medicine and Montefiore Medical Center, Department of Internal Medicine, Division of Hospital Medicine, Bronx, NY USA


An 88-year-old woman with a history of hyperparathyroidism and osteoporosis presented with 3 days of increasing fatigue, non-bloody emesis, and black stools. She had stable vital signs, but was ill-appearing. Her epigastrium was non-tender, however melena was discovered on rectal examination. Laboratory studies revealed a hemoglobin of 6.4 g/dl from a baseline of 10 g/dl (reference range 12.0-15.5 g/dl). A chest X-ray revealed no free air.  Esophagogastroduodenoscopy identified a large, non-bleeding, cratered, gastric ulcer with a view of the liver through a 1 cm perforation (Figure 1).

Figure Legend:  Endoscopic image of a 5 x 6 cm non-bleeding, cratered ulcer with 1 cm perforation and view of liver (black arrow).

The liver was seen prolapsing in and out of the perforation.  She underwent a successful emergent laparoscopic partial gastrectomy with gastrojejunostomy and was discharged home on pantoprazole. Biopsies were negative for H. pylori and malignancy.



1) What is the most common complication of Peptic Ulcer Disease (PUD) in the United States?


a) Hemorrhage

b) Obstruction

c) Perforation

d) Gastric Cancer

2) What is/are the more common clinical manifestations of a patient with a perforated peptic ulcer? 


a) Sudden abdominal pain, tenderness, and rigidity

b Elevated body temperature

c) Hypovolemia

d) Melena

e) A, B, and C

Click here for MCQ Answers and Discussion

Author descriptions:


Rashmi Advani is a resident in Internal Medicine at Montefiore Medical Center, Moses and Weiler Division. She is originally from Bayside, New York and completed her medical degree at SUNY Downstate Medical Center. In her free time, Dr. Advani likes to cook, take spinning classes, and explore her culinary interests in the five boroughs.


Benjamin Galen is an Assistant Professor of Hospital Medicine at Albert Einstein College of Medicine and Montefiore Medical Center.  He trained in internal medicine at Yale University where he was elected to the Gold Humanism Honor Society and was the class speaker at residency graduation.  He joined Montefiore and Einstein in 2013 as an inpatient teaching attending.  Dr. Galen is currently the Director of Ultrasound and Procedure training as well as core faculty in The Einstein/Montefiore Internal Medicine Residency Program.