Perforated duodenal ulcer presenting with a subphrenic abscess revealed by plain abdominal X-ray films and confirmed by multi-detector computed tomography: a case report

Abstract

IntroductionPeptic ulcer disease is still the major cause of gastrointestinal perforation despite major improvements in both diagnostic and therapeutic strategies. While the diagnosis of a perforated ulcer is straightforward in typical cases, its clinical onset may be subtle because of comorbidities and/or concurrent therapies.Case presentationWe report the case of a 53-year-old Caucasian man with a history of chronic myeloid leukemia on maintenance therapy (100mg/day) with imatinib who was found to have a subphrenic abscess resulting from a perforated duodenal ulcer that had been clinically overlooked. Our patient was febrile (38.5°C) with abdominal tenderness and hypoactive bowel sounds. On the abdominal plain X-ray films, a right subphrenic abscess could be seen. On contrast-enhanced multi-detector computed tomography, a huge air-fluid collection extending from the subphrenic to the subhepatic anterior space was observed. After oral administration of 500cm3 of 3 percent diluted diatrizoate meglumine, an extraluminal leakage of the water-soluble iodinated contrast media could then be appreciated as a result of a perforated duodenal ulcer. During surgery, the abscess was drained and extensive adhesiolysis had to be performed to expose the duodenal bulb where the ulcer was first identified by methylene blue administration and then sutured.ConclusionsWhile subphrenic abscesses are well known complications of perforated gastric or duodenal ulcers, they have nowadays become rare thanks to advances in both diagnostic and therapeutic strategies for peptic ulcer disease. However, when peptic ulcer disease is not clinically suspected, the contribution of imaging may be substantial.

Laparoscopic repair for perforated peptic ulcer: our experience, a comparison with the open approach and a review of the literature.

“…In literature, negative factors for the laparoscopic approach are shock at the diagnosis, delayed presentation (> 24 h), confounding medical conditions, age > 70 years, ASA (American Society of Anesthesiologists) score 3-4 and Boey score of ≥ 2, ulcer location or large perforation size (> 6-10 mm). The most accepted but discussed contraindication is signs of shock due to the negative impact of increase duration of surgery and negative influence of pneumoperitoneum on renal function [33]. For the laparoscopic approach the concern is the CO2 pneumoperitoneum who leads to increased intra-abdominal pressure intraoperatively: it is related to growing risk of bacteremia and sepsis due to the increased chance of bacterial translocation from peritoneal cavity into the bloodstream, increasing the occurrence of pneumonia in patients selected for this approach [34].…”

Review of Pancreaticoduodenal Trauma with a Case Report

“…Duodenal perforation can also be detected with radiograms following administration of gastrografin via nasogastric tube [18]. As a longstanding method, diagnostic peritoneal lavage (DPL) is a diagnostic procedure used in duodenal injuries [19].…”

“…Penetrating injuries of duodenum may be treated by debridement and primary repair or resection with anastomosis. For grade 1 cases, if there is intramural hematoma present and does not get resorbed within 2-4 weeks via conservative approach (nasogastric tube and parenteral nutrition), gastroduodenostomy + primary repair is recommended [18]. It is more common in patients who have bleeding diathesis or receive anticoagulant therapy [26,27].…”

Focus on the Perforated Peptic Ulcer

“…Negative factors for the laparoscopic approach are shock, delayed presentation (> 24 h), confounding medical conditions, age > 70 years, ASA (American Society of Anesthesiologists) score III-IV and Boey score of ≥ 2, ulcer location or large perforation size (> 6-10 mm). The most accepted contraindication is signs of shock due to the negative impact of increase duration of surgery and negative influence of pneumoperitoneum on renal function [47]. For the laparoscopic approach the concern is the pneumoperitoneum for CO 2 who leads to increased intra-abdominal pressure intraoperatively and is related to increased risk of bacteremia and sepsis due to the increased chance of bacterial translocation of peritoneal cavity into the bloodstream, increasing the occurrence of pneumonia in patients submitted to this approach [48].…”