Diagnostic laparoscopy for missed perforated duodenal ulcer; … · 2015-05-11 · duodenal ulcer;...

Article ID: WMC004874 ISSN 2046-1690

Diagnostic laparoscopy for missed perforatedduodenal ulcer; case reportPeer review status:No

Corresponding Author:Dr. Basem Othman,Minimal Invasive Surgery Consultant, General Surgery Department, Alhada Armed Forces Hospital, AlhadaArmed Forces Hospital, Taif, Saudi Arabia - Saudi Arabia

Submitting Author:Dr. Mohammad Othman,Consultant Obstetrician and Gynaecologist, King Abdullah Medical City, Maternity and Children Hospital,Madinah, Saudi Arabia, 84 Bradfield Road, M32 9LE - United Kingdom

Other Authors:Dr. Sarah kashgary,Intern, General Surgery Department, Alhada Armed Forces Hospital, Alhada Armed Forces Hospital, Taif, SaudiArabia - Saudi Arabia

Dr. Ghiad Alquthami,Intern, General Surgery Department, Alhada Armed Forces Hospital, Alhada Armed Forces Hospital, Taif, SaudiArabia - Saudi Arabia

Dr. Abdulrahman Alaryni ,General Surgery Resident, General Surgery Department, Alhada Armed Forces Hospital, Alhada Armed ForcesHospital, Taif, Saudi Arabia - Saudi Arabia

Dr. Mohammad Al Adwani,Colorectal Surgery Consultant, General Surgery Department, Alhada Armed Forces Hospital, Alhada ArmedForces Hospital, Taif, Saudi Arabia - Saudi Arabia

Article ID: WMC004874

Article Type: Case Report

Submitted on:17-Apr-2015, 03:44:14 PM GMT Published on: 20-Apr-2015, 12:51:09 PM GMT

Article URL: http://www.webmedcentral.com/article_view/4874

Subject Categories:SURGERY

Keywords:Kissing Ulcer, Laparoscopy, Duodenal Ulcer, Perforated Ulcer, Report, Conservative treatment

How to cite the article:Othman M, kashgary S, Alquthami G, Alaryni A, Othman B, Al Adwani M. Diagnosticlaparoscopy for missed perforated duodenal ulcer; case report. WebmedCentral SURGERY2015;6(4):WMC004874

Copyright: This is an open-access article distributed under the terms of the Creative Commons AttributionLicense(CC-BY), which permits unrestricted use, distribution, and reproduction in any medium, provided theoriginal author and source are credited.

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Diagnostic laparoscopy for missed perforatedduodenal ulcer; case reportAuthor(s): Othman M, kashgary S, Alquthami G, Alaryni A, Othman B, Al Adwani M

Abstract

Perforated peptic ulcer is a common abdominaldisease that is treated by surgery. Despite the use ofproton pump inhibitors, perforated peptic ulcer remainsa frequent surgical emergency with an averagemortality rate of 5.8%. This is a report of a 77 year oldSaudi diagnosed as acalculus cholecystitis and uponlaparoscopic exploration it was found to be sealedduodenum perforation. Patient was treatedconservatively and discharged in good condition.

Introduction

Diagnostic laparoscopy is a minimally invasive surgicalprocedure [1]. It was first introduced in 1901, whenkelling performed a peritoneoscopy in a dog and wascalled "Celioscopy" [1-3]. A Swedish internist namedJacobaeuse performed the first Diagnosticlaparoscopy on human in 1910 [1, 3].The diagnosticvalue of emergency laparoscopy has been provedsince the 1950s and 1960s [2, 4]. Emergencydiagnostic laparoscopy with surgical intervention wasfirst proposed by Philippe Moment in 1990.[2, 4, 5]

Diagnostic laparoscopy offers the potential advantageof visually excluding or confirming the diagnosis ofacute intra-abdominal pathology expeditiously withoutthe need for a laparotomy [3, 6, 7]. It is the mostaccurate method even compared to open laparotomy ,recommended and accepted worldwide [8]. The mainadvantage of diagnostic laparoscopy over traditionalopen laparotomy is reduced morbidity, decreasedpostoperative pain, and a shortened length of hospitalstay [1, 4, 8]. It is safe well tolerated and can beperformed in an outpatient and inpatient setting undergeneral anesthesia.[2, 6]

The introduction of Helicobacter pylori eradicationtherapy and the use of proton pump inhibitors have ledto a decline in the incidence of perforated peptic ulcers(PPU) [1, 7]. Despite this, PPU remains a frequentsurgical emergency with an average mortality rate of5.8% in a recent review of the literature [1, 2, 6, 7].Perforation is the second most common complicationof peptic ulcer disease and surgery is almost alwaysindicated [7, 9, 10]. If left untreated beyond 24 hours,

the mortality approaches 50% [7, 8, 10]. Surgicalmanagement usually involves an upper midlinelaparotomy and repair of the perforation with acombination of simple suture repair and pedicledomentoplasty [4, 6, 10]. The first successfullaparoscopic suture repair for perforated peptic ulcerwas described by Nathanson in 1990 [2-4]. Soon afterthat, the laparoscopic approach became a widespreadprocedure [6]. Laparoscopic repair of duodenalperforation is a useful method for reducing hospitalstay, complications and return to normal activity [3, 8].

Non-operative treatment has been shown to be safeand effective in selected patients, although, it isdifficult to predict reliably of those who will respondsuccessfully [4, 5]. It is known that perforated ulcersfrequently seal spontaneously by the adherence of theomentum of organs adjacent to the ulcer [8-10].

Case Report(s)

A 77 years Saudi woman known case of hypertension, 2ry hyperparathyroidism , and Cohn's disease onpotassium replacement, diuretic, and lyrica. She waspresented to the emergency department complainingof abdominal pain before five days, improve after twodays, then back one day prior to presentation. Painstarted at flanks bilaterally then localized at umbilicus,radiated to back and both shoulders, stabbing innature, no aggravating and reliving factors. Associatedwith anorexia, nausea, and vomiting (which waspostprandial with food content).

Patient didn’t give any history of heartburn, gastricreflux, or using NSAID medication. Patient deny anychange of bowel habit , urine color, or stool color. Also,she deny getting fever at home, or loss of weight inlast year. No abnormality was detected in othersystems. She had no surgical history.

On examination she was afebrile, Blood Pressure125/70, Pulse 87. Abdomen was not distended, noscars seen and hernia orifices intact. By palpationabdomen was soft but marked tenderness over theepigastric area and right upper quadrant with nopalpable mass. Bowel sounds were normal.

Laboratory investigations were normal apart fromleukocytosis (18.6×103 U/l), elevated calcium ( 2.73mmol/L ) , elevated lactic acid ( 2.9 mmol/L ) and



elevated CRP (9.1 mg/l). Plan erect chest X-Rayshowed no air under diaphragm and Plan supineabdominal X-ray showed no bowl dilatation.Abdominal Ultrasound revealed normal pancreas,bilateral kidneys, normal gall bladder with no stoneinside, but the liver was fatty liver. AbdominalComputed Tomography (Figure 1, Figure 2) reporteddistended thick wall gall bladder with precystic fluidand small rime of fluid surrounding the liver, with nohypodense stricture inside the gall bladder.

Provisional diagnosis of acute acalculus cholecystitisfor diagnostic laparoscopy. Intra-operativelylaparoscopy revealed sealed perforated duodenalulcer with small food particle and pus at the adherentomentum (Figure 3, Figure 4). Drain was inserted.Patient started on Proton Pump Inhibitor (Pantozol40mg IV infusion) and single antibiotic (Tazocine4.5grams IV TID) as conservative management for twodays.

Patient was discharged in good condition on third dayon oral diet and Pantozol 40mg orally once daily.

Discussion

Perforation of a peptic ulcer is potentially fatal surgicalemergency that remains a formidable health burdenworldwide. The global prevalence of peptic ulcerdisease has decreased in recent decades, but this hasnot been followed by a similar reduction incomplications from peptic ulcers [4, 5]. The reductionin peptic ulcer disease is in part explained by theintroduction of antibacterial therapy to eradicateHelicobacter pylori and the widespread use of protonpump inhibitors (PPIs) [5, 9]. Yet, despite theintroduction of PPIs, the rate of peptic ulcer perforationhas remained stable in several regions of the world [4,6, 7]. Improved medical management of peptic ulcerdisease has virtually eradicated the need foracid-reducing surgery, such as proximal selectivevagotomy, and gastric resection [9, 10]. Thecomplications of peptic ulcer disease, however, inparticular bleeding and perforation, continue to presentas an emergency [10]. Bleeding ulcers are five timesmore common than perforated ulcers. Non-operativemanagement, including medication, endoscopy andinterventional radiology, has decreased the role ofemergency surgery to less than 2 per cent of patients[3, 7, 8].

The clinical presentation of acute pain in the upperabdomen, with signs of peritonitis, is typical for PPU,but is seen in only about two-thirds of patients [5, 9].When present, peritonitis is an indication for

immediate laparoscopy or laparotomy, taking intoaccount the patient’s condition and observations [4, 8].Delay should not be introduced by additional imaging.Fewer than one-third of patients have a history ofpeptic ulcer disease before perforation [3, 7, 9]. Erectchest X-ray, seeking free air under the diaphragm, hasbeen the imaging procedure of choice historically, butthe diagnostic yield is suboptimal and free air isreported to be visible at rates varying from 30 to 85per cent. X-ray has now been replaced by abdominalcomputed tomography (CT), which has a higherdiagnostic yield, reportedly around 70–98 percent. Inaddition, CT can rule out other differential diagnosesof importance (such as acute pancreatitis) that wouldrule out the need for surgery. Ultrasonography may beuseful in experienced hands and can locate the site ofulcer perforation [4, 6, 8]. The role of ultrasonographyis limited and it should not delay surgery if otherdiagnostic procedures have confirmed the presence offree air, or the patient is ill.

Perforated peptic ulcer can be treated by a wide rangeof options that varies from conservative non-operativetreatment to immediate definitive ulcer surgery [2, 4, 8].Some patients with perforated ulcer can be managedsuccessfully by non-operative means. The chiefobjections to this treatment are uncertainty or error indiagnosis, the unknown site and pathology of theperforation, and the unlikely response in elderlypatients in whom this treatment is more attractive.However, routine definitive ulcer surgery in the form ofhighly selective vagotomy has been suggested inpatients with perforated duodenal ulcer because thisoperation is unlikely to cause long-term side effectsand because the prediction of the clinical course aftersimple repair of the ulcer is unreliable [4, 5, 10].However, immediate definitive ulcer surgery forperforated peptic ulcer agrees that simple repair isindicated for patients who are poor surgical risksbecause of major concurrent medical illness or shock,for patients who have heavy bacterial contamination ofthe peritoneal cavity because of delay in surgery, andwhen experienced surgeon is not available [4, 5, 7].Fewer surgeons currently have acquired enoughexpertise in performing highly selective vagotomy withadvances in medical therapy. Simple closure remainsan attractive option for perforation in most centers.Reports of laparoscopic treatment have shown thatperitoneal toilet can be performed effectively andperforations can be closed safely. Whether repair ofthe perforation by the laparoscopic approach is betterthan by conventional open repair is undetermined.Laparoscopic repair of perforated peptic ulcer can bedone by the suture or the sutureless technique [4, 5, 7,8, 10].



Conclusion

Every effort should be done to diagnose perforatedulcer. Radiological investigations can be misleading. Itis crucial to have high index of suspicion forcomplications of perforated ulcer, in order to managethem appropriately. Thus, appropriate clinical decisionmaking should not be delayed by suboptimal imaging.

Plain abdominal imaging harbors a substantial risk forfalse negative results. Accordingly, when imaging isused, low-dosage CT scan should be preferred.

References

1. Abdulrahman, W. and R. Mishra, DiagnosticLaparoscopy Versus Exploratory Laparotomy. 2014,World Labaroscopy Hospital.

2. Bertleff, M., et al., Randomized Clinical Trial ofLaparoscopic Versus Open Repair of the PerforatedPeptic Ulcer: The LAMA Trial. World of GeneralSurgery, 2009. 33: p. 1368–73.

3. Golash, V. and P. Willson, Early Labaroscopy as aroutine procedure in the management of acuteabdominal pain. Surgical Endoscopy, 2005. 19: p.882-5.

4. Thorsen, K., et al., Trends in Diagnosis and SurgicalManagement of Patients with Perforated Peptic Ulcer.Journal of Gastrointestinal Surgery, 2011. 15: p.1329-35.

5. Søreide, K., K. Thorsen, and J. Søreide, Strategiesto improve the outcome of emergency surgery forperforated peptic ulcer. Wiley Online Library, 2013.101: p. e51–e64.

6. Chang, H. and W. Choi, Nonoperative Treatment ofPerforated Duodenal Ulcer: A Case Report andReview of the Literature. Journal of Emergency CriticalCare in Medicine. Vol. 168 18, No. 4, 2007. 18(4): p.167-71.

7. Critchley, A., et al., Management of perforatedpeptic ulcer in a district general hospital. Annals of TheRoyal College of Surgeons of England, 2011. 93 p.615–19.

8. Lau, W., et al., A Randomized Study ComparingLaparoscopic Versus Open Repair of PerforatedPeptic Ulcer Using Suture or Sutureless Technique.Annals of Surgery, 1996. 224( 2 ): p. 131-8.

9. Rathod, J., et al., Upper gastrointestinal bleeding:audit of a single center experience in Western India.Clinics and Practice, 2011. 1(e132): p. 292-5.

10. Vahedian, J., et al., Duodenal Kissing Ulcer(Sealed Anterior Perforated Duodenal Ulcer Combinedwith Hemorrhagic Posterior Ulcer): Report of a Case.Govaresh, 2010. 15(3): p. 243-6.



Illustrations

Illustration 1

Figure 1: CT scan



Illustration 2

Figure 2: CT scan 2



Illustration 3

Figure 3: Laparoscopy picture 1



Illustration 4

Figure 4: Laparoscopy picture 2


Diagnostic laparoscopy for missed perforated duodenal ulcer; … · 2015-05-11 · duodenal ulcer;...

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