Perforated duodenal ulcer

Case contributed by Dr Michael P Hartung

Presentation

Upper abdominal pain, nausea, and vomiting.

Patient Data

Age: 65 years
Gender: Male
CT

Perforation of the medial aspect of the 2nd portion of the duodenum. Reactive inflammation of the 2nd and proximal 3rd portion of the duodenum. 

Air and fluid are tracking in the retroperitoneum. Specifically, it is in the anterior pararenal space (anterior margin = peritoneum, posterior margin = anterior renal/Gerota fascia). 

PRE/POST OPERATIVE DIAGNOSIS:

Perforated duodenal ulcer.

OPERATIONS:

  1. Exploratory laparotomy. 
  2. Open cholecystectomy. 
  3. Pyloric exclusion.
  4. Placement of retrograde duodenostomy tube. 
  5. Gastrojejunostomy creation. 
  6. Gastrostomy tube placement. 
  7. Jejunostomy tube placement.
  8. Creation and mobilization of omental flap

FINDINGS: 

Duodenal perforation at the medial aspect of the second to third portion of the duodenum distal to the ampulla with gross spillage of bile that tracked down the retroperitoneal space. 

DETAILS OF THE PROCEDURE:

...We then began medializing the right colon by dissecting off the peritoneal attachments. After doing so, we were able to identify the duodenum. There was gross spillage and staining of bile in this area. This was then suctioned. We were able to identify the duodenum and bluntly dissected the duodenum, the second and third portion. We were able to identify a perforation to the duodenum on the medial aspect, kind of the transition between the second and third portions of the duodenum that appeared distal to the ampulla. There was gross spillage of bile that then also tracked down into the right colic gutter  retroperitoneal space that we were able to suction up. We then planned to do a pyloric exclusion given the proximity of his gallbladder and need to take down the hepatogastric ligaments. We performed an open cholecystectomy. We dissected the gallbladder off of the liver and identified the cystic duct. We placed a 2-0 silk suture around the cystic duct and divided the cystic duct on the gallbladder side of this and sent this specimen as the gallbladder...

Case Discussion

This case provides a good review of retroperitoneal anatomy. The perforated air and fluid track in the anterior pararenal space. Notice how most of the oral contrast did not spill through the ulcer defect. The ulcer crater/defect can be well seen on the coronal reformatted images. 

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Case information

rID: 65708
Published: 19th Jan 2019
Last edited: 14th Aug 2019
Inclusion in quiz mode: Included

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