Peritonitis secondary to a blocked perforated ulcer: management
Amine Chaabouni1,a. Haroun Guermazi1. Mohamed Ali Mseddi1. Kais Fourati1
General Surgery Department, Habib Bourguiba Hospital, University of
Sfax, 3029 Sfax, Tunisia
a Corresponding author: amine_chaabouni@yahoo.com
Written informed consent was obtained from the patient to publish this
report.
Introduction:
Peptic ulcer disease (PUD) is a common request for medical care. Most
often benign, they are sometimes complicated by hemorrhage or
perforation, which can drastically alter the prognosis. In this report,
we will concern ourselves with sealed perforated ulcers. In the context
of actual trends towards an efficient and non aggressive treatment as
surgery carries additional morbid-mortality, this condition generates a
therapeutic debate between those who favor a preventive strategy aimed
at operating the patient in order to avoid the death; and those who
follow a conservative strategy which only refers the patient to the
operating theatre in the case of deterioration. We will be reporting on
our own experience with a contained perforated duodenal ulcer which was
operated on secondarily after non-response to medical treatment.
Case report:
Patient N D, 42 years old, smoker with no pathological history,
presented to his primary care physician complaining of cramp
epigastralgia evolving during 03 days. The biology showed
leukocytes=15.3*10^3/mm3 of which 65% PNN, hemoglobin=17.5 g/100mL
platelets=343*10^3/mm3, C-reactive protein(CRP)=2mg/L
PCT<0.05ng/mL, D-dimer=1755.710 ng/mL troponin=1,5 ng/L,
lipase=33UI/L, urea=2mmol/L, Prothrombin Ratio=98%
,plain
abdominal X-ray= no pneumoperitoneum. He had a symptomatic medical
treatment.The evolution was marked by the persistence of the pain,
dyspnea and sinus tachycardia at 140ppm. He was tested for SARS Covid by
PCR with a nasopharyngeal swab which came back negative. An abdominal
thoraco CT scan without injection showed a pulmonary parenchymal
condensation in the apical segment of the right lower lobe, atelectasis
band under the basal segment bilaterally, spasmodic aspect of the
antropyloric region with satellite adenomegaly with small size,
diverticula of the sigmoid and the right colon. A transthoracic
echocardiography showed a non-dilated non hypertrophied left ventricle
(LV) with moderate decrease of the systolic function of the LV
(LVEF=58%), pericarditis of low abundance. He was put under bisoprolol
then ivabradine for a better control of the cardiac frequency.
Considering the non decrease of his abdominal pain after 48h and the
association of fever and vomiting, he had an upper digestive fibroscopy
which revealed a very inflammatory aspect of the stomach with big soft
and oedematized antrofindic folds, permeable pylorus, very inflammatory
bulb with presence of a big bulbic ulcer quite excavated occupying the
small curvature and the anterior face of the bulb with inflammatory
narrowing of the bulbar top which remains crossed with hard friction by
the fiberscope. A complement of injected abdominal CT scan and with high
digestive opacification with water-soluble showed the appearance of
disorders of ventilation of the two bases associated with a right
pleural effusion, the appearance of a peri-hepatic effusion and at the
level of the right parieto colic gutter with densification of the
mesenteric fat next to the gastric antrum without leak of contrast agent
in extra digestive (figure 1). He was put under nasogastric aspiration,
infusion, cefotaxime, metronidazole, gentamicin, double dose of
omeprazole and surveillance in an intensive care unit. After 24 hours,
in front of the persistence of febrile state and guarding in the
physical exam, we decided to operate by laparoscopic approach: the
intraoperative exploration showed a diffuse purulent intraperitoneal
effusion with multiple false membranes barring the duodenal bulb,
abscess under hepatic - under right diaphragmatic and in Douglas’
fornix. Appendix and gall bladder were apparently healthy. He had an
aspiration of the purulent contents and the flattening of the abscessed
collections. Methylene blue test turned out to be negative. The abundant
toilet with physiological serum was accompanied by installation of
drainage in right sub phrenic, under left phrenic, under hepatic and in
the pouch of Douglas. The evolution was marked by apyrexia,
restoration of transit on day 01 postoperative; the left sub phrenic
drain brought back regularly 100mL sero-hematic for 04 days. Other
drains only brought back 100mL sero-hematic on the first day, drop in
leukocytes to 11.000 and CRP to 145.7. Methylene blue test was made on
day 04 postoperative, in front of the negative result, the gastric tube
was removed and he was allowed to eat. The drainage was removed the next
day considering food tolerance. He returned to his home on Day 06
postoperative. He had an eradication of helicobacter pylori. He was seen
02 weeks after, no functional complaints were reported.
Discussion:
The ulcer generates pain in the form of cramps in the pit of the
stomach, more rarely burning sensations. They are generally triggered by
food intake. Non-steroidal anti-inflammatory drugs (NSAIDs) and the
Helicobacter pylori bacteria alone are responsible for the vast majority
of ulcers. In fact, a quarter of chronic NSAID users will develop PUD
[1]. Although the incidence of PUD has decreased in recent years due
to the eradication treatment for Helicobacter pylori and the use
of proton pump inhibitors [2], complications of PUD such as
perforation and bleeding have remained fairly constant[3]. This may
be related to increased use of NSAIDs and to the aging population
[4].
The anterior surface of the 1st duodenum is the most prevalent location
(60%) before the gastric antrum (20%) and then the lesser gastric
curve (20%)[5].
Duodenal perforations can either be free or contained. Free perforation
arises when bowel contents leak freely into the abdominal cavity and
causing diffuse peritonitis. Contained perforation occurs when the ulcer
creates a full-thickness hole, but free leakage is prevented by
contiguous organs such as the pancreas wall off the area[6].
Perforated ulcers may seal spontaneously with fibrin, omentum or by
fusion of the duodenum to the underside of the liver between the
gallbladder and the falciform ligament.
Considering the phagocytic capacities of the peritoneum and the frequent
sterility of the effused fluid, and the fact that the perforation
”covered” itself most of the time, allowed surgical treatment to be
omitted.
This led E. \Y. Bedforil-Turner in 1945 to propose a
conservative treatment consisting of morphine to ease the pain, emptying
of the stomach, and permanent aspiration. These measures were then
consolidated by H. Taylor the following year, after the experience of 28
cases, which also made it possible to specify the indications[7].
The technique consists of: administration of intravenous analgesic
treatment, aspiration of tummy contents, hydration of the patient by
parenteral or rectal route, by introducing the quantity of liquid
withdrawn from the stomach plus 1 and 1/2 to 2 liters.
Taylor’s results are sensational: among the 28 cases enrolled in the
first Taylorization study, 24 uneventful recoveries, 3 deaths for
non-digestive reasons, and only one peritonitis by reopening of the
sealed ulcer in an undisciplined subject who had drunk after the
perforation. It should be added that two cases had to be operated on
secondarily when confronted with the finding of contracture persisting.
These results are corroborated by recent results emanating from the
prospective study of
Cristina
Dascalescu and al. [8]which evaluated the security of Taylor’s
treatment. Among 64 patients, 89% responded to medical treatment with
no need to invasive action. Among 4 patients who developed
intra-abdominal abscesses only 2 required drainage but no additional
mortality was noted.
With a success rate of around 85%, a further study led by Ruangsak
Nusree published in The THAI Journal of SURGERY. He has highlighted that
surgery can be prevented.
In the light of the reassuring results of these studies and the fact
that the perforation could close spontaneously by filling it by the
neighboring organs (liver, gallbladder, round ligament, epiploon), which
occurs in about 50% of cases [9], medical treatment can be safely
pursued.
These authors do not propose to systematically renounce surgical
treatment of perforated ulcers, but they grant the conservative method
the following indications
- Patient seen shortly after perforation (maximum 6 hours);
- Perforation occurring long after a meal, when the stomach can be
assumed to be empty;
- General condition too precarious to undergo the operation;
- Distance from a surgical centre (ships at sea, etc.).
This method recognizes the opposite contraindications:
- Late patients;
- Patients who have been drinking after the perforation;
- Suspicion of an abundant peritoneal effusion;
- Gastric stasis due to pyloric stenosis;
- Uncertain location of the ulcer;
- Repeated perforation: operate on the second, without waiting for a
third one!
Non-operative treatment may fail and lead to the constitution of a
suppuration neighboring the perforation or spreading into the large
peritoneal cavity. With the spillage of intraluminal contents into the
peritoneal cavity, chemical peritonitis occurs. This is followed by a
systemic inflammatory response syndrome (SIRS), which can progress to
secondary bacterial peritonitis and sepsis [10].
The treatment thus proposed will join the usual attitude in front of an
ulcerous peritonitis: a cleansing associated with an exclusion of the
perforation.
In our case, no gesture was performed on the origin of the peritonitis,
only a meticulous cleansing was proposed. Our judgment was based on the
principle of the physiological defense mechanisms as described above and
the worry of inflicting further contamination if an attempt was made to
expose the perforation if the abscess cavity bursts during surgery.
Eradication of H. pylori was prescribed considering the fact that
H.pylori prevalence ranges are from 50% to 80% in patients with
perforated duodenal ulcers [11]. In addition, 85.3% percent of
ulcers were healed in the triple therapy group as opposed to 48.4% in
the omeprazole alone group as mentioned by Kin Tong Chung and
Vishalkumar G Shelat [1].
We did not perform an endoscopy follow-up as it is not recommended due
to the low risk of malignancy in such patients [12].