A Case of Idiopathic Perforation in the Third Portion of the Duodenum Occurred 17 Years after Distal Gastrectomy

Abstract

An 84-year-old woman who underwent gastrectomy with Billroth-II reconstruction 17 years earlier was seen at a neighboring hospital because of the abrupt onset of upper abdominal pain after lunch. Thereafter she vomited and was referred to our hospital on the next day. There were tenderness, muscular defense, and rebound tenderness in the right upper quadrant of abdomen. Blood examination revealed an increase in the inflammatory reaction. Abdominal contrast-enhanced CT scan showed abdominal free air and fluid collection in the caudal side of the third portion of the duodenum. From these findings, emergency operation was carried out with a diagnosis of perforation of the third portion of the duodenum 26 hours after the onset of the disease. Upon laparotomy there were about 300 ml of brownish ascites in the abdominal cavity and a perforated site with the size of a pin hole at the inferior wall of the third portion of the duodenum. No diverticulum or ulcerative lesion was seen at the perforated site. Operative procedures included simple closure of the duodenum, placement of a tube to the duodenum for decompression, and drainage of the abdominal cavity. The patient was discharged from the hospital on the 30^th postoperative day. In this case we could not identify any secondary factors including ulceration, afferent loop syndrome, diverticulum, foreign body like a fish bone, trauma, and tumor. Idiopathic perforation in the third portion of duodenum was considered to be the final diagnosis.