Perforated marginal ulcer following Whipple procedure: A case reportAbstractMarginal ulcers are rare complications of pancreatoduodenectomy. Patient can present with varying symptoms such as epigastric discomfort, pain, dysphagia, or can land in emergency with complications like bleeding and perforation.IntroductionWhipple procedures are performed for variety of benign and malignant lesions affecting the pancreatic head, duodenum, and distal bile duct.1 Marginal ulcer, one of the rare long term complications of pancreatoduodenectomy, are ulcerations that occur at or around the gastrointestinal anastomosis.2 Their associated morbidity and mortality have been infrequently described in literature.3 Here we present a case of a gentleman with a 6 year old history of Whipple procedure who presented in emergency department with acute onset abdominal pain and was later diagnosed with perforated marginal ulcer.Case presentationA 64-year-old retired soldier who underwent the Whipple procedure six years ago for carcinoma head of pancreas, adenocarcinoma (well-differentiated adenocarcinoma) presented to emergency department with complaints of severe abdominal pain for a one day on the day of presentation. The pain was acute in onset, continuous, non-radiating, and increasing in severity, which used to be aggravated after ingestion of food and movement. He had three episodes of vomiting since morning on the day of presentation. On his past history, he underwent the Whipple procedure six years ago and has received complete six cycles of chemotherapy after surgery. He was under irregular follow-ups for past two years. The patient had no other comorbid illnesses.On his arrival to the emergency department, his pulse rate was 130beats per minute, regular; oxygen saturation 85 % on room air; blood pressure 110/70 mm Hg, body temperature 38.7 ◦C, and respiratory rate(RR) 22 breaths/min. On his physical examination, his abdomen was distended with diffuse tenderness. There was diffuse guarding and rigidity all over the abdomen. Bowel sounds were absent. Digital rectal examination revealed a normal sphincter tone with a collapsed rectum and absent fecal stain on the gloved finger. He was immediately administered crystalloids and supplemental oxygen at 4 L/min. Nasogastric tube decompression and Foley catheterization were done. His laboratory parameters showed leukocytosis with raised amylase. Liver function test revealed total bilirubin 1.80 mg/dL, conjugated bilirubin 0.8 mg/dL and alkaline phosphatase 712U/L. On radiological examination, supine abdominal X-ray showed prominent dilated small bowel loops and free gas under right hemi diaphragm pointing towards hollow viscous perforation (Fig. 1). Ultrasonography of the abdomen and pelvis was unremarkable with minimal free fluid in the pelvis.After an initial fluid resuscitation, an emergency laparotomy was done. Intraoperatively, The findings were 300 ml of bilious fluid in the peritoneal cavity and dense adhesion between the small bowel loops and previous surgical scar. Adhesions were meticulously released and gastrojejunostomy site perforation was there, which was around 1 cm Fig.1. A thorough peritoneal lavage was done and the gastrojejunostomy site perforation was closed with a well-vascularized omental patch after a biopsy from the ulcer edge. He received Meropenem IV 1 g and Vancomycin IV 500 mg twice daily along with low molecular weight Heparin 60 mg twice daily the following day. His condition gradually improved and was discharged on 10th post operative day.
