A 63-year-old male was admitted after requesting voluntary discharge from the hospital due to persistent severe abdominal pain, nausea, vomiting and malaise.
The patient came 5 days before to this center for sudden severe pain in the right hypochondrium, accompanied by nausea and vomiting.
Among his close history he had been operated on a perforated duodenal ulcus 14 months before; treated with simple closure and omentum repair (Graham technique).
Helicobacter pylori was not mentioned and was subsequently treated with 20 mg/day.
Among his remote history, he was diagnosed with PU at 23 years of age.
He smoked 20 cigarettes/day and drank 80-100 mg of alcohol/day to date.
At this center, an endoscopy was performed, which revealed a stomach with food cramps, and a double pylorus image with one of the orifices and another blinded bleeding. The rest of the exploration was performed through endoscopy.
A barium study was performed 24 hours later, in which a pyloric stenosis was observed.
Pain persistence decided to go to our center.
On admission, the patient presented with abdominal tenderness and right flank hypochondrium.
Heart rate was 140 bpm.
TA: 103/72 mmHg.
Oxygen saturation: 96% with room air, leukocytes 11.8 x 103 μL; 67.1% neutrophils; 23.6% monocytes; platelets 25,000 u/l hemoglobin 12.3 g/dl normal; fibrinogen 877
During admission she had fever (38.5 oC), leukocytosis 12,000/ul with left shift; C-reactive protein 29 mg/l (normal values 0.8 mg/l).
A large collection (> 10 cm diameter) with signs of double bubble, free air and extravasation of barium contrast to the retroperitoneum was observed on plain abdominal radiography and abdominal ultrasound.
An urgent laparotomy was performed, finding a large collection occupying the entire right parietocolic gout.
A large Kocher maneuver showed a perforation of a giant ulcus (> 3 cm) in the posterior aspect of the duodenum.
Due to the size of the perforation, the time of evolution (> 48 hours) severe contamination and the patient's ulcerous history, a Bilroth II type antrectomy was performed with a round ointment of the duodenal defect.
Contaminated retroperitoneal space was covered with vascularized major omentum plasty and closed aspiration drainage (Jackson-Pratt®) was left after abdominal cavity washed.
Six days after the intervention a collection of 23.1 x 8.4 x 6.5 cm was observed in the flank and right iliac fossa, which was drained under ultrasound control, isolating polymicrobe flora.
The patient was discharged 16 days after the intervention in good general condition.
Pathology report: normal gastric wall and mucosa without the presence of Helicobacter pylori.
