Peptic ulcer disease complicated with choledocho-duodenal fistula and gastro-intestinal bleeding: a case report and review of the literature

Abstract

Peptic ulcer disease (PUD) is a very common condition, with an annual incidence ranging from 0.1% to 0.3% and a lifetime prevalence ranging from 5% to 10%. If not treated, it can lead to severe complications such as gastro-intestinal bleeding, perforation, or entero-biliary fistula. Entero-biliary fistulas and especially choledocho-duodenal fistula (CDF) are a rare, but relevant and important diagnosis, which can lead to several complications such as gastric outlet obstruction, bleeding, perforation, or recurrent cholangitis. In this article, we present the case of an 85-year-old woman with PUD complicated with gastro-intestinal bleeding and a CDF. We also performed a review of the literature to search for pre-existing cases with this atypical clinical presentation. The aim was to raise awareness among surgeons and clinicians by offering a summary of different types of entero-biliary and especially CDF, existing diagnostic investigations, and management.

Endoscopic Vacuum-Assisted Closure (E-VAC) in Septic Shock from Perforated Duodenal Ulcers with Abscess Formations

“…The perforation of duodenal ulcers (PDUs) is more common than gastric ulcers, with an incidence higher in men [4]. Transmural perforated ulcerative lesions result in duodenal content oozing into the peritoneal cavity [4][5][6]. This presents an irritating local process contaminated with microbial germs, leading to peritonitis [1,2,5].…”

“…Transmural perforated ulcerative lesions result in duodenal content oozing into the peritoneal cavity [4][5][6]. This presents an irritating local process contaminated with microbial germs, leading to peritonitis [1,2,5]. Fistulas can form in the subhepatic space, right parietal colic space, pouch of Douglas, and peritoneal cavity.…”

“…The free air accumulates under the diaphragmatic dome, resulting in a bilateral pneumoperitoneum. The erosive process of PDUs is due to acid hypersecretion, diet, or stress [4][5][6]. More specific factors favoring perforation include stress, physical fatigue, seasonal painful pustules, ulcerogenic medication, abdominal trauma, excessive food intake, surgical instrumental maneuvers, and imaging diagnostics.…”

“…Additional symptoms include pain exacerbation upon movement, irradiation to the right hypochondrium, sporadic early vomiting of gastric content, and hematemesis. Physical signs are cold sweats, shallow breathing, tachycardia with normal blood pressure, and a transient subsiding of pain, which is worse upon recurrence [1,2,5,6]. Rare cases with more insidious progression have been recorded, where the patient presents to the hospital with symptoms of less severe complications.…”

“…By the time a clinical examination has been completed, a differential diagnosis based on the history and physical exam should be established. This can be an elaborate list, including but not limited to conditions such as inflammation (acute pancreatitis and cholecystitis), intussusception, volvulus, ischemia, lithiasis, ulcers, hemorrhage, and perforation [1,2,5,6]. At this stage, an upright chest and abdominal X-ray (X-radiation) is a rapid and costeffective method that can help to narrow down the differential diagnosis but does have a significant false negative rate.…”