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CASE REPORT
Year : 2016  |  Volume : 2  |  Issue : 3  |  Page : 155-157

Perforated duodenal ulcer: A rare cause of acute abdomen in children


Department of Pediatric Surgery, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi, India

Date of Web Publication7-Oct-2016

Correspondence Address:
Dr. Simmi K Ratan
Department of Pediatric Surgery, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi - 110 002
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2394-7438.191687

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  Abstract 

Duodenal ulcer perforation is uncommon in children which is why it is not usually considered in the differential diagnosis of acute abdomen in them. In this brief report, we are presenting a case of successfully managed perforated duodenal ulcer in a child. Another interesting point was the presence of air only under right hemidiaphragm, a sign generally known to be associated with duodenal perforation.

Keywords: Acute abdomen in children, duodenal ulcer perforation, pneumoperitoneum


How to cite this article:
Sisodiya RS, Ratan SK, Tripathi B. Perforated duodenal ulcer: A rare cause of acute abdomen in children. MAMC J Med Sci 2016;2:155-7

How to cite this URL:
Sisodiya RS, Ratan SK, Tripathi B. Perforated duodenal ulcer: A rare cause of acute abdomen in children. MAMC J Med Sci [serial online] 2016 [cited 2019 Sep 22];2:155-7. Available from: http://www.mamcjms.in/text.asp?2016/2/3/155/191687


  Introduction Top


Duodenal ulcer is an infrequently diagnosed disease in children. [1],[2] Being rare and, moreovered, due to a low index of suspicion on the part of physicians, it usually presents with serious complications such as perforation or gastrointestinal bleeding. [3] Perforated appendicitis is usually considered to be the most likely cause of acute abdomen than the involvement of a more proximal portion of gut (duodenum) in an otherwise healthy child.

Here, we are reporting a case who presented in emergency with features of acute abdomen. X-ray showed localized free air under right dome of the diaphragm. On exploration, surprisingly, duodenal perforation was found which was repaired successfully.


  Case Report Top


A 3-year-old male child presented to pediatric surgical emergency with a history of fever, pain in abdomen, distension of abdomen, and no passage of stool for 2 days. The child had a history of analgesic and antipyretic intake for a week before presentation but none of hematemesis or malena. On physical examination, the child was lethargic, dehydrated, and had tachycardia and tachypnea. Cardiac examination was within normal limits. Chest examination revealed right-sided decreased air entry. The abdomen was distended, tender, and demonstrated generalized guarding with rebound tenderness. Liver dullness was masked, and bowel sounds were absent. Upright chest and abdominal radiograph showed the presence of localized free air under right dome of the diaphragm associated with right moderate pleural effusion [Figure 1]. After initial fluid resuscitation and intercostal chest tube drainage insertion that drained 100 ml of serous fluid, the child was taken up for emergency laparotomy with a provisional diagnosis of hollow viscus perforation peritonitis. At surgery, 8 mm × 4 mm perforation was seen on the anterior wall of the first part of duodenum [Figure 2] with moderate peritoneal contamination in the neighboring region. Stomach and pyloric region were unremarkable. Rest of the viscera were normal. Simple closure with omental patch (Graham's) followed by peritoneal lavage was performed, and the abdomen was closed with drain in the subhepatic space. The initial postoperative period was quite critical due to poor chest condition requiring the Intensive Care Unit care; however, subsequent recovery was uneventful. The patient was discharged on the 10 th day. Histopathology of ulcer margins revealed ulceration with chronic inflammation with eosinophils. On 2-month follow-up, the patient is well, and contrast study shows well-healed duodenum with no stricture [Figure 3].
Figure 1: X-ray showing free gas under right dome of diaphragm and right pleural effusion

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Figure 2: Duodenal perforation

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Figure 3: Contrast study at 2 months of follow-up

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  Discussion Top


Duodenal ulcer disease does not usually present in pediatric surgical practice unless complicated by bleeding or perforation. [3] Its exact incidence and pathogenesis are debatable though one Indian series had reported the incidence as 1.55 cases per year. [3] Risk factors for peptic ulcer disease in children are similar to those in adults: Helicobacter pylori infection (the most common cause), Zollinger-Ellison syndrome, sickle cell anemia, blood group "O" or secondary to medications (such as nonsteroidal anti-inflammatory drug [NSAID]), and corticosteroids or physiological stress (burns, head injury, and mucosal ischemia). [1] In children (<10 year of age), duodenal ulcers secondary to NSAIDS predominate in comparison to those with H. pylori infection due to the frequent use of this. [3] Our patient had "O" blood group as well as NSAID intake due to febrile illness and both of these are well recognized predisposing factors for the entity.

One noteworthy point in this patient was the presence of air under right hemidiaphragm only while left hemidiaphragm was clear of it. Such sign is seen in few instances, of which duodenal perforation is frequently cited. [3]

The other conditions frequently found to be particularly associated with air under right hemidiaphragm are right subphrenic abscess and Chiladiti syndrome; the latter found very rarely among children. In our patient, the clinical history and sign were in agreement to the possibility of perforated duodenal ulcer, and it was confirmed per-operatively.

Various surgical procedures are described to deal with duodenal perforation, and these include simple closure with omental patch, truncal vagotomy and drainage procedure and hemigastrectomy. [3],[4],[5] Simple closure of perforation with omental patch with care not to obstruct the duodenal lumen is commonly performed in emergency settings as was done by us too.

Recurrence is rarely reported in children, thereby obviating the need of vagotomy. Another reason is that vagotomy is seen to be associated with more gastrointestinal dysfunction in children than in adults which should be taken care of. [3]

To summarize, acute duodenal ulcer perforation is a rare surgical emergency in pediatric practice, requiring a high index of suspicion to diagnose it and simple closure to surgically treat it.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Mohta A, Shrivastava UK, Gupta BP, Gupta A. Perforated duodenal ulcer in a child. Indian Pediatr 2002;39:578-9.  Back to cited text no. 1
[PUBMED]    
2.
Hua MC, Kong MS, Lai MW, Luo CC. Perforated peptic ulcer in children: A 20-year experience. J Pediatr Gastroenterol Nutr 2007;45:71-4.  Back to cited text no. 2
[PUBMED]    
3.
Kadian YS, Rattan KN, Malik A. Perforated duodenal ulcer a rare cause of acute abdomen in infancy: A report of two cases. Afr J Paediatr Surg 2008;5:46-7.  Back to cited text no. 3
[PUBMED]  Medknow Journal  
4.
Yadav RP, Agrawal CS, Gupta RK, Rajbansi S, Bajracharya A, Adhikary S. Perforated duodenal ulcer in a young child: An uncommon condition. J Nepal Med Assoc 2009;48:165-7.  Back to cited text no. 4
    
5.
Morrison S, Ngo P, Chiu B. Perforated peptic ulcer in the pediatric population: A case report and literature review. J Ped Surg 2013;1:416-9.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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