Perforated duodenal ulcer: A rare complication of deferasirox in children

Abstract

Duodenal ulcer perforation in pediatric age group is an uncommon entity; hence, it is not usually considered in the differential diagnosis of acute abdomen in these patients. It is important for the emergency physician to consider perforated peptic ulcer in the differential diagnosis of children presenting with acute abdominal pain, gastrointestinal bleeding, or shock. We report a 6½-year-old male child with thalassemia major who presented to emergency room with an acute abdomen and shock, who was subsequently found to have a perforated duodenal ulcer, probably related to use of oral chelating agent, deferasirox. Although, gastrointestinal symptoms like nausea, vomiting, and abdominal pain has been mentioned as infrequent adverse event in the scientific product information of deferasirox, in our current knowledge this is the first case report of perforated duodenal ulcer after oral deferasirox. The severity of this event justifies the reporting of this case. This patient had an atypical presentation in that there were no signs or symptoms of peptic ulcer disease before perforation and shock he was successfully managed with open surgery after initial resuscitation and stabilization of his general condition.

Duodenal Ulcus Perforation: An Unusual Cause of Acute Abdomen in Pediatrics

“…Therefore, diagnosis can not be generally made before the development of complications such as bleeding and perforation. Even sometimes, as was seen in our patient, diagnosis is made during laparotomy (1,2,5,6).…”

“…Wilson et al (7) demonstrated the presence of subdiaphragmatic free air in a 7-year-old patient with duodenal perforation who presented with symptoms of gastroenteritis. Yadav et al (2) revealed the presence of duodenal perforation in a 6.5-year-old case with thalassemia major under deferasirox therapy. Mbarushimana et al (10) reported a patient who consulted them with complaints of lower abdominal pain, and vomiting lasting for 4 hours.…”

“…Since peptic ulcer disease is not seen very frequently in the pediatric age group, it does not very often come to one's mind among the causes of abdominal pain occurring in children, and diagnosis can be made only after the emergence of complication(s). Although formation of acid, and pepsin are the most important factors in the development of peptic ulcer, serious stress, Helicobacter pylori, familial predisposition, systemic diseases, burn wounds, head trauma, and drug release (NSAIDs, and steroids) also play critical roles (1,2,6).…”

“…Primary duodenal ulcer is associated with H.pylori infection. Secondary ulcer disease is linked with external predisposing factors such as medications, trauma, surgery, and stress (1)(2)(3)5,7).…”

“…Most of the cases with primary duodenal ulcers are related to Helicobacter pylori infection. Predisposing factors such as serious stressful conditions, systemic diseases, head traumas, burns, surgical interventions, and drug use (NSAIDs) accompany secondary duodenal ulcers (1)(2)(3)(4).…”