Case History and Examination
A 73-year-old male was admitted to the emergency department with abdominal pain, off and on for 2-3 months, along with post prandial blood-stained vomiting. He reported that for the last 2 days, the pain had become constant, localized to the epigastric region. On the day of admission, the patient had felt dizzy, and had had a fall- a source of concern for the patient and his family. However, the fall was not associated with any injury or loss of consciousness. The patient also stated alteration of bowel habits, in addition to weight loss, which he had been referred to the fast-track colorectal clinic. The medical background was significant for hypertension, hypercholesterolemia, and basal cell carcinoma (Mgx?). There were no prior surgeries, or allergies. He did not take any NSAIDs, or blood thinners. The medical examination revealed a frail, pale elderly gentleman, awake and alert with a GCS of 15/15, and some haemodynamic instability (SBP – 71 mmHg with normal pulse) on admission. His abdominal examination revealed a rigid abdomen with generalized tenderness, and involuntary guarding. Bowel sounds were audible.

Investigations, Treatment, and Outcome
The routine blood samples taken on admission were significant for a raised white cell count of 17.5, with a CRP of 1.0 and a lactate of 7.09, whereas the rest of tests did not yield any pathological findings. A plain abdominal radiograph showed pneumoperitoneum?. The patient was managed with intravenous fluids, antibiotics, analgaesics, and intravenous proton pump inhibitors while awaiting an urgent CT. The urgent CT abdomen + thorax with oral and intravenous contrast showed evidence of hollow viscus perforation, a distended oesophagus, and stomach, with cut off point at the pylorus, as well as ascites (Figure 1). During his admission, the patient’s inflammatory markers worsened (CRP - 311 White cell count -17.5), and his lactate rose to 8.39. The aforementioned blood results, coupled with the patient’s now compromised haemodynamic status, prompted urgent surgical intervention.

The patient underwent laparotomy, with serosal patch repair of a perforated duodenal ulcer, and washout. Prior to the surgery, ITU team was taken on board for post-operative monitoring of the patient. The operation was done under general anaesthesia. A midline laparotomy incision was made. The intra-operative findings were four quadrant biliary peritonitis, involving the entirety of bowel loops and the omentum (Figure 2). A perforated duodenal ulcer measuring 1 – 1.5 cm was seen at the junction of the first and second parts of the duodenum, with the ante-mesenteric border of the duodenum completely eroded by the ulcer (Figure 3).

Four-quadrant washout was done using warm water, and the second part of the duodenum was kocherized. The lesser sac was entered to visualize the stomach and to determine the possibility of resection of the stomach. However, given the proximity of the ulcer to vital structures like the ampulla of vater, along with the perplexity involved with identifying the common bile duct, and the cystic duct due to severe chemical inflammation from the intraluminal contents, made it unsafe to proceed with resection. A decision was made to place a serosal patch over the perforated ulcer, using the proximal jejunum, which was held in place using 2/0 vicryl (Figure 4). Four Robinson’s drains were placed, 1 in the area of the ulcer, 1 each in the right and left paracolic gutters, and 1 in the pelvis.

The patient needed a post-operative admission to ITU for 6 days, owing to his severely compromised haemodynamic status (Anuria and hypotension in spite of double nor-adrenaline support). He also developed new onset atrial fibrillation post operatively, which was managed with amiodarone. He was kept on ventilatory support for 3 days, following which he self-extubated andmaintained saturation on room air. Vasopressor support was weaned off as well, as the patient was able to maintain a target mean arterial pressure of > 65mmHg.

The patient was stepped down to a surgical ward and was started on TPN as per nutritional team’s advice. He was also managed with intravenous hydration to improve post operative AKI, as well as intravenous antibiotics, and intravenous PPI. A water-soluble swallow was done on the 9^th post-operative day, which showed a contained focal leak in the 1^st part of the duodenum. Hence, oral intake was not restarted, and TPN was continued. A repeat water-soluble swallow done about 1 month post-operatively, showed no leak, following which oral intake was resumed, and the patient was weaned off TPN. The patient tolerated oral diet well and was soon back to his pre-operative baseline.

During his hospital course, the patient started spiking temperatures, and had a rise in inflammatory markers. The patient received a course of Pipercillin/Tazobactum for 14 days, and fluconazole for 10 days. A repeat CT abdomen + pelvis was done, which showed a peri-splenic collection, (Figure 5) for which the patient underwent ultrasound guided aspiration. Following this, the patient clinically improved. After a hospital stay of 39 days, the patient was deemed medically fit for discharge to a rehabilitation centre on oral PPI for a total of 6 weeks. The lead surgeon was of the notion that he would require reconstruction of this area, with biliary and enteric diversions, if the patient survived.