Perforated duodenal ulcer

Case contributed by Dr Michael P Hartung

Presentation

Abdominal pain.

Patient Data

Age: 75
Gender: Male
CT

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: 76-year-old man who presents through the emergency department with severe abdominal pain and frank peritonitis. 

PROCEDURE DETAILS:
A midline incision extending from the xiphoid process to the umbilicus was made with a #10 scalpel. Subcutaneous tissue was divided with electrocautery. The midline fascia was carefully opened and the abdomen was entered. The falciform ligament was divided near the umbilicus and then freed up and spared. The retractors were placed and the abdomen was explored. He had obvious gastric contents scattered throughout the abdomen, particularly near the hepatic fossa. The area was irrigated and aspirated clean. 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. A Kocher maneuver was performed elevating the duodenum into the wound. The edges of the perforation were actually quit clean.

After further evaluation, the decision was made to perform a primary closure with imbricating 3-0 silk sutures. This was done transversely with a running 3-0 Vicryl suture and then imbricating 3-0 silk sutures. The previously spared tongue of falciform ligament was then laid over the top of the repaired area and sewn in place with 3-0 silk sutures as well. Attention was then turned to the lesser curve of the stomach. The patient was thin and evaluation was easy. Several branches on the anterior and posterior aspect of the lesser curve of the vagus nerve extending to the antrum and body of the stomach were identified. They were individually teased out and clipped proximally and distally with small clip applier and then divided with scissors. A small segment of sample nerve was sent to pathology. Four branches on the anterior side and 3 branches were divided on the posterior side. A 19 French closed suction drain was then brought through a separate stab incision in the right upper quadrant and placed posterior to the duodenal closure site. The area was then copiously irrigated with 4 liters of warm normal saline and aspirated clean in all quadrants...

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 outpouching 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.

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Case information

rID: 61851
Published: 20th Jul 2018
Last edited: 14th Apr 2019
Inclusion in quiz mode: Included

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