A case of intractable duodenal ulcer accompanied by the choledochoduodenal fistula which needed the operation

Abstract

While hospitalized in our department of internal medicine for the treatment of allergic purpura and nephrotic syndrome, a 61-year-old male patient developed abdominal pain. A workup revealed free gas in the abdominal cavity and the patient was diagnosed as having a perforated duodenal ulcer. He underwent CT-guided drainage and received proton-pump inhibitor (PPI) therapy while the dose of steroids was reduced. He underwent emergency surgery since the perforation recurred, but drainage alone was performed since the perforation was not identified at that laparotomy. Improvement in the patient's general condition was awaited. 2 weeks later, under the judgment that the patient was having intractable duodenal ulcer with posterior wall perforation, surgery was performed again. There was a large base of the ulcer in the upper half of the descending part of the duodenum and a flow of bile from the base was observed. Intraoperative cholangiography was performed and the cholangiogram from the ulcer base only showed the common bile duct. The patient was diagnosed as having choledochoduodenal fistula and selective gastric vagotomy, partial gastrectomy and cholecystojejunostomy were performed. The postoperative course was uneventful. The patient achieved remission and was discharged from the hospital. While peptic ulcers are usually managed with medical therapy such as PPI therapy, duodenal ulcers penetrating the common bile duct as in the patient of this case should be managed with surgical intervention.