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Benign tumors of stomach and duodenum are not common and constitute only 5–​10% It is crucial to note that a definite diagnosis cannot be achieved without.
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• INFLAMMATORY LESIONS OF THE STOMACH AND DUODENUM | JAMA | JAMA Network
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Here we report a case of a large posterior perforation of a duodenal ulcer and a review of the literature. A year-old man was admitted with a complaint of a constant dull aching pain in the epigastrium for five days, which progressively worsened and generalized. No history of comorbidities, not smoker, no alcohol intake, insignificant family or medical history.

The patient was febrile on admission, and his vital signs were unstable. The abdomen was tender all over with board-like rigidity.

An emergency laparotomy was therefore performed. During the laparotomy, collection of pus was found, with no perforation in the anterior surface of the stomach or duodenum; the rest of the gastrointestinal tract was regular.

The gastrocolic omentum was opened, and pus was drained out from the lesser sac. A 2-cm perforation of the posterior duodenal wall was noted. The lesser sac was approached through opening of the gastrohepatic omentum, pancreas was soaked with the gastric secretions and looked to be partially digested, the ulcer margins were attached to the pancreas, mobilization of the second part of the duodenum was done, the ulcers margins where biopsied, duodenotomy to approach and close the defect with stitching using vicryl, Heineke-Mikulicz pyloroplasy at the end.

Recovery was not smooth, the patient was kept in an intensive care unit for ten days because of sepsis, respiratory distress syndrome, pancreatitis, at the end patient recovers entirely and was sent home after 20 days of hospitalization. Figure 1. Posterior perforation of a duodenal ulcer is a rare condition.

There are fewer than 30 cases reported in the literature. Wong and colleagues reviewed nine patients with posterior perforations, who were treated from January to June Their findings were sealed perforation, localized retroperitoneal abscess, and generalized peritoneal contamination of the lesser sac and peritoneal cavity 5 , 6. In a series of consecutive perforated peptic ulcer patients operated upon by Hamilton Bailey, there was only one case of perforation on the posterior surface of the duodenum 6.

The great majority of benign duodenal ulcers lie along the anterior aspect of the duodenum. When posterior duodenal ulcer perforates, it usually penetrates the lesser sac behind the stomach. The lesser sac is a potential space and is less effective in sealing off the perforation; thus, the gastric content and pus will accumulate in the lesser sac, forming an abscess, and through the foramen of Winslow this fluid will pass into the peritoneal cavity, leading to generalized peritonitis 5.

That is why the clinical presentation of posterior duodenal perforation is less dramatic than that of the more common anterior perforations and is characterized by the late presentation. And because of the late presentation and missed diagnosis at laparotomy, posterior perforation is usually associated with high mortality 1 , 2 , 5 , 8. These ulcers penetrate into the retroperitoneal space, which results in either retroperitoneal abscess formation, or the perforation will be sealed off by the local inflammatory reaction and fibrosis of the surrounding adherent retroperitoneal tissue 5.

Computed tomography CT scanning has an important role, particularly multidetector CT, in the diagnosis of perforated peptic ulcer and the determination of the site of perforation. Posterior perforation of duodenal ulcers has high mortality. Delayed diagnosis due to insidious and presentation of symptoms and missed diagnosis at laparotomy are major contributory factors. Posterior perforations if delayed, are associated with peritonitis sepsis and multi-organ failure. In cases of purulent peritonitis performing the definitive surgical procedure is a contraindication, and only damage controlled surgery should be performed.

In the badly scarred and contracted duodenum the matter of both secure closure and adequate channel for gastric emptying must be considered. Editorial Board.

If you would like to automatically receive newletters and alerts from the BioMedPress, please fill in the form below. Advertising Policies. This work is licensed under a Creative Commons Attribution 4. Skip to main content Skip to main navigation menu Skip to site footer. HTML Total Article Details. Issue: Vol 5 No 1 Page No. Table of Contents.

Downloads Download data is not yet available. Keywords: duodenal ulcer posterior perforation a surgical emergency. Competing Interests. The author s declare that they have no competing interests. Jarrett F. The primary function of the small intestine is to pass nutrients through the intestinal wall to the blood. This blood is carried from the small intestine to the liver for filtering, removal of toxins and nutrient processing.

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Most absorption takes place in the small intestine. As chyme enters the duodenum it is mixed with bile which helps digest fat , pancreatic juices and enzymes, and intestinal enzymes. Surgical removal of the stomach is sometimes performed, especially in patients with cancers originating in the stomach. This type of surgery is called a gastrectomy. Sometimes the entire stomach is removed and sometimes only a portion of the stomach will be removed. Nearby organs, such as the pancreas, gall bladder or spleen may need to be removed as well. Click on the image to view a Wikipedia definition of each organ.

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Some patients that have had gastrectomies suffer from a condition known as Dumping Syndrome. Dumping Syndrome is caused when food moves too rapidly into the small intestines.

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The incidence and severity of symptoms are directly related to the extent of gastric surgery. The symptoms can be divided into two stages, early stage and late stage. Early stage symptoms occur 15 to 60 minutes after eating. They are caused when sugar and simple carbohydrates pass too rapidly into the small intestine. Patients taking Gleevec need to find the balance that works for them.

Gleevec can cause nausea, even in patients that have never had any kind of stomach surgery. Drinking water during a meal may help reduce the nausea caused by Gleevec. On the other hand, drinking too much with a meal may increase the severity of dumping syndrome. Treatment consists of a post-gastrectomy diet, high in protein, and low in carbohydrates and concentrated sugars.

Small frequent meals 6 or more per day , with limited liquids during meals are generally recommended.

People with severe rapid gastric emptying may need to take prescribed medicine to slow their digestion. Your doctor may prescribe medicines. Medicines to slow the passage of food may be prescribed by your doctor.

Medicines that may be prescribed include:. Vitamin B12 is absorbed in the small intestine with the aid of a stomach secretion called intrinsic factor. Loss of intrinsic factor results in a vitamin B12 deficiency in patients with a gastrectomy. Patients that have had a gastrectomy will generally require regular vitamin B12 shots. Oral vitamin B12 may be given as an alternative. Oral vitamin B12 with intrinsic factor will probably be absorbed better than oral vitamin B12 alone, however it is not clear if the additional vitamin B12 that a patient would absorb by taking the combination is actually required.