Presentation
Abdominal pain.
Patient Data
Small perforated ulcer in the lateral aspect of the second portion of the duodenum. Multiple locules of free intraperitoneal air in the upper abdomen. Small amount of perihepatic fluid and stranding, and a small amount of ascites elsewhere. Perihepatic fluid is high density (75 Hounsfield units), consistent with a mixture of oral contrast and reactive fluid. Moderate distention of the stomach with oral contrast. Few oval filling defects surrounded by oral contrast within the lumen of the pylorus and first portion of the duodenum could represent ingested material or intraluminal clot from the ulcer if bleeding is present.
PREPROCEDURE DIAGNOSIS: Perforated duodenal ulcer.
POSTPROCEDURE DIAGNOSIS: Perforated duodenal ulcer.
PROCEDURE: Exploratory laparotomy with repair of perforated duodenal ulcer and highly selective vagotomy.
INDICATIONS: Male presents through the emergency department with severe abdominal pain and frank peritonitis.
PROCEDURE DETAILS (selected details):
He had obvious gastric contents scattered throughout the abdomen, particularly near the hepatic fossa. With further evaluation he had an obvious approximately 0.5 cm perforated anterior duodenal ulcer. There was no active bleeding. There was a fair volume of gastric contents in the abdomen.
Case Discussion
Perforated duodenal ulcer resulting in free intraperitoneal air, peritonitis, and small amount of free fluid. Case highlights the utility of oral contrast, which confirms the diagnosis as there is higher density (75 Hounsfield units) perihepatic fluid, indicating a mixture of enteric contents and oral contrast. The luminal out pouching can be confidently seen along the lateral aspect of the second portion of the duodenum. The adjacent intraluminal filling defects could represent clot or ingested material.