Duodenal perforation in children: must surgery be performed?

Abstract

Objective：The aim of this study is to share our experience in the conservative treatment of duodenal perforation in children. Method：Retrospective collection of clinical data on 6 children with duodenal perforation treated at Fujian Children's Hospital from May 2022 to October 2023. Six cases were all males, ranging in age from 8 to 14 years old, and the onset time ranged from 4 to 24 hours. Main manifestations are abdominal pain, vomiting, fever, etc. Among them, 5 children have undergone abdominal CT examination at local hospitals, indicating gastrointestinal perforation. Result：All 6 patients were diagnosed with perforation of the anterior wall of the duodenum, of which 5 cases were confirmed by ultrasound examination to be located in the bulb, and 1 case was located at the junction of the bulb and the descending part. The perforation diameter of all cases was less than 1cm.Four of them were less than 5mm, and 1 case was 6.9mm. Abdominal X-ray plain film showed 3 cases of free gas downstream of the diaphragm. Five cases underwent conservative treatment, including fasting, gastrointestinal decompression, antibiotics, proton pump inhibitor (PPI), octreotide, and nutritional support. Blood routine monitoring showed that white blood cell (WBC) count and C-reactive protein (CRP) level gradually returned to normal. They recovered after 10-16 days of hospitalization. One case underwent emergency laparoscopic repair of duodenal perforation due to sepsis after 2 days of conservative treatment. Complications such as chyloperitoneum, pleural effusion and subphrenic effusion occurred after the surgery, and the patient recovered after 34 days of hospitalization. All patients recovered and were discharged. Continue to take omeprazole acid therapy for 8 weeks after discharge. All cases were followed up for a period of 1 month to 1 year. Only 1 patient underwent gastroscopy 3 months later and, diagnosed with multiple duodenal ulcers (S2 stage), and continued treatment. The remaining 5 cases showed no signs of second time perforation, bloody stools, abdominal pain, or vomiting. Conclusion：Duodenal perforation in children is rare and often caused by primary ulcers. Most of them has a history of chronic abdominal pain, with symptoms of abdominal pain, vomiting, fever, and signs of peritonitis during acute attacks. Abdominal X-ray, abdominal CT plain scan, and ultrasound can assist in diagnosis. As long as there is no progression to sepsis, conservative treatment can achieve the same therapeutic effect as surgical treatment, with satisfactory outcomes and acceptable hospital stay.