Post-bulbar duodenal ulcer with anterior perforation with kissing ulcer and duodenocaval fistula: A case report and review of literature

Abstract

BACKGROUND A post-bulbar duodenal ulcer (PBDU) is an ulcer in the duodenum that is distal to the duodenal bulb. PBDU may coexist with a synchronous posterior ulcer in rare occurrences, resulting in a kissing ulcer (KU). Duodenocaval fistula (DCF) is another uncommon but potentially fatal complication related to PBDU. There is limited knowledge of the scenarios in which PBDU is complicated by KU and DCF simultaneously. CASE SUMMARY A 22-year-old man was admitted to the emergency department with abdominal pain, stiffness, and vomiting. The X-ray showed pneumoperitoneum, suggesting a perforated viscus. Laparotomy revealed a KU with anterior perforation and a DCF. After Kocherization, venorrahphy was used to control caval bleeding. Due to the critical condition of the patient, only primary duodenorrahphy with gastrojejunostomy was performed as a damage control strategy. However, later, the patient developed obstructive jaundice and leakage, and two additional jejunal perforations were detected. Due to the poor condition of the duodenum and the involvement of the ampulla in the posterior ulcer, neither primary repair nor pancreatic-free duodenectomy and ampulloplasty/ampullary reimplantation were considered viable; therefore, an emergency pancreaticoduodenectomy was performed, along with resection and anastomosis of the two jejunal perforations. The patient had a smooth recovery after surgery and was discharged after 27 d. CONCLUSION The timely diagnosis of PBDU and radical surgery can aid in the smooth recovery of patients, even in the most complex cases.

Duodenocaval fistula after bevacizumab therapy: case presentation and complete overview of the literature

“…Peptic ulcers were responsible for the remaining cases (11, 19.6%) [ 5 , 11 , 13 , 14 , 26 ]. Only large ulcers accounted DFC, because the mean ulcer diameter was 4.4 cm (range, 1.5–9 cm).…”

Closed-Loop Gastric Outlet Obstruction Secondary to Duodenal Ulcer in a Patient With Esophageal Stricture

“…Duodenal ulcers occur due to the disruption of mucosal integrity and are included in the broader category of peptic ulcer disease [3]. Duodenal ulcers present commonly in the duodenal bulb area, whereas 5% to 10% of duodenal ulcers occur in the post-bulbar region and, even more rarely, in the third portion of the duodenum [4,5]. Clinical manifestations of post-bulbar duodenal ulcer (PBDU) are still not well established, making diagnosing and treatment difficult [5].…”

“…Patients with GOO can present with abdominal pain, nausea, weight loss, melena, and hematemesis [5]. However, many conditions overlap with these symptoms, so a precise diagnosis and treatment are needed to address duodenal ulcers before complications like GOO occur.…”