A previously healthy 50-year-old man presented with a 2-week history of right flank pain, and 2 days of fever, chills and vomiting. Physical examination and urinalysis were suggestive of pyelonephritis. Urine culture was positive for Escherichia coli. Noncontrast computerized tomography (CT) was performed to evaluate for ureterolithiasis and obstruction. No calculi were seen but the right kidney exhibited mild pelviec-tasis and stranding around the pelviureteral junction. In addition, a gas bubble was seen in the bladder, prompting contrast enhanced CT (part A of figure). Delayed images demonstrated contrast passage from the right renal pelvis into the second portion of the duodenum (part B of figure). Subsequent upper endos-copy showed a giant post-pyloric bulbar ulcer. Gastric cultures were positive for Helicobacter pylori. The patient was treated with antibiotics and maintained on a proton pump inhibitor.
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