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CASE REPORT
Year : 2016  |  Volume : 35  |  Issue : 1  |  Page : 74-76

A large posterior perforation of gastric ulcer: a rare surgical emergency


Hepatobiliary Surgery Unit, General Surgery Department, Alexandria Faculty of Medicine, AlexandriaHepatobiliary Surgery Unit, General Surgery Department, Alexandria Faculty of Medicine, Alexandria, Egypt

Date of Submission29-Aug-2015
Date of Acceptance24-Oct-2015
Date of Web Publication18-Feb-2016

Correspondence Address:
Amr A Badawy
MS, Hepatobiliary Surgery Unit, Alexandria Faculty of Medicine, Alexandria
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-1121.176828

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  Abstract 

A 65-year-old woman was admitted with a complaint of a constant dull aching pain in the epigastrium for 4 days, with subsequent worsening and generalization of the pain. Clinically the abdomen was tender all over with board-like rigidity. Chest radiography revealed pneumoperitoneum and a decision was made to explore the patient. During laparotomy we found mild peritoneal collection with no perforation in the anterior surface of the stomach, duodenum, or the entire gastrointestinal tract. After opening the gastrocolic omentum, we found a large perforation of the posterior wall of the stomach. After direct repair with an omental patch, the patient recovered and was discharged after 14 days, with only wound infection. Posterior perforation of a gastric ulcer is a very rare condition.

Keywords: Gastric ulcer, posterior perforation, surgical emergency


How to cite this article:
Badawy AA. A large posterior perforation of gastric ulcer: a rare surgical emergency. Egypt J Surg 2016;35:74-6

How to cite this URL:
Badawy AA. A large posterior perforation of gastric ulcer: a rare surgical emergency. Egypt J Surg [serial online] 2016 [cited 2017 Oct 18];35:74-6. Available from: http://www.ejs.eg.net/text.asp?2016/35/1/74/176828


  Introduction Top


Every year peptic ulcer affects four million people globally [1]. Complications are encountered in 10-20% of these patients and 2-14% of the ulcers perforate [2],[3]. Perforated peptic ulcer is relatively rare, and occurs usually in the anterior aspect of the duodenum [4].

Posterior perforation of gastric ulcer is a unique category of peptic ulcer perforation with a distinct clinical presentation [5]. Despite its rareness, awareness of this surgical emergency is very important, because it is usually associated with high morbidity and mortality especially if the diagnosis is missed.

Here we report a case of a large posterior perforation of a gastric ulcer and a review of the literature.


  Case report Top


A 65-year-old woman was admitted with a complaint of a constant dull aching pain in the epigastrium for 4 days, which progressively worsened and generalized. She had a history of diabetes mellitus and ischemic heart disease.

The patient was febrile on admission and her vital signs were stable. The abdomen was tender all over with board-like rigidity. Chest radiography demonstrated pneumoperitoneum and the patient was diagnosed with generalized peritonitis due to perforated hollow viscus.

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

The gastrocolic omentum was opened and pus was drained out from the lesser sac. A 3-cm perforation of the posterior gastric wall of the body of the stomach was noted [Figure 1] and [Figure 2]. We took a biopsy from the ulcer margins, and then closed the perforation with an omental patch. The biopsy was insignificant. The patient recovered and was discharged after 14 days, with wound infection.
Figure 1: Posterior perforation of the gastric ulcer.

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Figure 2: Posterior perforation of the gastric ulcer.

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  Discussion Top


Posterior perforation of a gastric ulcer is a rare condition. There are fewer than 30 cases reported in the literature. Wong and colleagues (2003) reviewed nine patients with posterior perforations, who were treated from January 1990 to June 2002. Their findings were sealed perforation, localized retroperitoneal abscess, and generalized peritoneal contamination of the lesser sac and peritoneal cavity [5].

In a series of 125 consecutive perforated peptic ulcer patients operated upon by Hamilton Bailey, there was only one case of perforation on the posterior surface of the stomach [6].

The great majority of benign gastric ulcers lie along the lesser curvature of the stomach. However, ∼5-8% of ulcers lie in the posterior wall of the body of the stomach [7].

When posterior gastric ulcer perforates, it usually penetrates into the lesser sac behind the stomach (for gastric ulcers in the fundus or body of 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 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 gastric perforation is less dramatic than that of the more common anterior perforations and is characterized by late presentation. And because of the late presentation and missed diagnosis at laparotomy, posterior perforation is usually associated with high mortality [5],[8].

In the case of posterior perforation of pyloric or duodenal ulcers, 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 in the determination of the site of perforation. There are particular findings in CT scanning that suggest gastric posterior wall perforation, such as retrogastric air and/or fluid collection [9].


  Conclusion Top


Posterior perforation of a gastric ulcer is a rare condition and should be suspected when there is collection of pus or gastric content intraperitoneally with no perforation in the whole gastrointestinal tract on exploration of the abdomen. It usually presents late and is associated with a high mortality rate. Operative findings depend on the location of the perforation with either a lesser sac abscess associated with generalized peritonitis or retroperitoneal abscess. An unexplained retroperitoneal abscess should always draw attention to the possibility of the presence of a posteriorly perforated peptic ulcer. CT scanning plays an important role in the diagnosis of the site of the perforated peptic ulcer.

Acknowledgements

The author thanks Professor Dr. Ahmed Shawky and Professor Dr. Alaa Hussein for their support and help in treating this case.

Consent: Written, informed consent was taken from the patient for reporting this case.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Zelickson MS, Bronder CM, Johnson BL, Camunas JA, Smith DE, Rawlinson D, et al. Helicobacter pylori is not the predominant etiology for peptic ulcers requiring operation. Am Surg 2011; 77:1054-1060.   Back to cited text no. 1
    
2.
Bertleff MJ, Lange JF. Perforated peptic ulcer disease: a review of history and treatment. Dig Surg 2010; 27:161-169.  Back to cited text no. 2
    
3.
Lau JY, Sung J, Hill C, Henderson C, et al. Systematic review of the epidemiology of complicated peptic ulcer disease: incidence, recurrence, risk factors and mortality. Digestion 2011; 84:102-113.   Back to cited text no. 3
    
4.
Williams N, Bullstrode C, Connell RO. Stomach and duodenum in Bailey and Love′s short practice of surgery. 25th ed. London: Arnold Publishers; 2008.   Back to cited text no. 4
    
5.
Wong CH, Chow PKH, Ong HS, Chan WH, et al. Posterior perforation of peptic ulcer: presentation and outcome of an uncommon surgical emergency. Surgery 2004; 135:321-325.  Back to cited text no. 5
    
6.
BW.Ellis. Perforated and obstructed peptic ulcer Hamilton Baileys emergency surgery. 12th ed. Oxford: Butterworth Heinemann Ltd; 1995. 359-362.  Back to cited text no. 6
    
7.
Musgrove JE. Posterior penetrating gastric ulcer. Can Med Assoc J 1955; 72:342-345.  Back to cited text no. 7
    
8.
Weston-Davies WH, Perkiewicz M, Szczygiel B. Retroperitoneal extravasation from perforated duodenal ulcer. Br J Surg 1988; 75:878-879.  Back to cited text no. 8
    
9.
Wang SY, Cheng CT, Liao CH, Fu CY, Wong YC, Chen HW, et al. The relationship between computed tomography findings and the locations of perforated peptic ulcers: it may provide better information for gastrointestinal surgeons. Am J Surg 2015. Available from:dx.doi.org/10.1016/j.amjsurg.2015.05.022.  Back to cited text no. 9
    


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