Duodenal perforation masquerading as an intra-abdominal abscess: successful management with pedicled falciformopexy

Abstract

Duodenal perforation typically presents as an acute abdomen. In contrast, presentation as an intra-abdominal abscess is rare and may delay diagnosis. We report a 25-year-old male who presented with 8 days of upper abdominal pain and 4 days of progressive abdominal distension. Despite marked abdominal distension, he had no signs of peritonitis. Laboratory investigations showed marked leukocytosis. Chest radiography showed no classical subdiaphragmatic free air, whereas computed tomography confirmed pneumoperitoneum. Emergency exploratory laparotomy revealed an intra-abdominal abscess with dense omental adhesions encasing the bowel. A 1 × 1 cm perforation on the anterior wall of the first part of the duodenum was identified. As the omentum was unsuitable for conventional patch repair, the perforation was successfully repaired using a pedicled falciform ligament flap. This case highlights an uncommon presentation of duodenal perforation and demonstrates the falciform ligament flap as an effective alternative when omental patch repair is not feasible.

Introduction

The annual incidence of peptic ulcer perforation ranges from 0.004% to 0.014%, with mortality ranging from 10% to 40% [1, 2]. Duodenal perforation typically presents with the life-threatening features of an acute abdomen. In contrast, an intra-abdominal abscess is a rare but clinically significant presentation of a subclinical or contained duodenal perforation and may be fatal if not recognized and treated promptly [3].

This case is noteworthy because it highlights a rare presentation of duodenal ulcer perforation as an intra-abdominal abscess in the absence of the classical features of perforation, such as generalized peritonitis and free subdiaphragmatic air. Furthermore, dense omental clumping with non-viable omentum precluded the use of a conventional omental patch, necessitating repair with a pedicled falciform ligament flap as an effective alternative.

Case presentation

A 25-year-old married male with no significant past medical or surgical history presented with upper abdominal pain for 8 days and progressive abdominal distension for 4 days. The pain had a sudden onset while he was at work and was initially localized to the epigastrium. It was continuous, stabbing, severe, non-radiating, and associated with multiple episodes of non-projectile, non-bilious, non-bloody vomiting. He also reported decreased appetite and loose stools (2–3 episodes/day) during the first 4 days of illness. The patient reported brief, self-limiting episodes of pricking epigastric pain occurring 2–3 times daily for 2 days, 20 days before presentation, with no recurrent symptoms until the current episode.

Four days after the onset of symptoms, he sought treatment at a local health post, where he received intravenous fluids and medications, resulting in partial relief of pain. Despite treatment, the pain gradually became diffuse, involving the entire abdomen. He subsequently consulted a traditional healer, but his symptoms did not improve. Eight days after the onset of symptoms, he presented to our emergency department with persistent mild abdominal pain, described as a stretching sensation due to progressive abdominal distension. There was no history of fever, nausea, or recent nonsteroidal anti-inflammatory drug use. He had a 7-year smoking history (~1.4 pack-years), consumed alcohol occasionally, and had no known drug allergies.

On examination, the patient was hemodynamically stable. Per abdominal examination revealed a grossly distended abdomen with an everted umbilicus. There were no signs of peritonitis. Preoperative laboratory investigations showed marked leukocytosis, with a total leukocyte count of 33 000/mm³ and 92% neutrophils; all other baseline parameters were within normal limits. A chest radiograph demonstrated hyperlucency at the base of the right hemi-thorax (Fig. 1); however, the classical crescent-shaped right subdiaphragmatic free air was absent. As the radiographic findings were inconclusive, a non-contrast computed tomography (CT) scan of the abdomen was performed, which confirmed pneumoperitoneum (Fig. 2).

After resuscitation, an emergency exploratory laparotomy was performed through a supraumbilical midline incision. On entering the peritoneal cavity, no free intraperitoneal collection was encountered. Instead, a thick, densely adherent layer of omentum covered the entire bowel, forming a membrane-like barrier (Fig. 3). The incision was therefore extended infraumbilically, which revealed ~2 l of foul-smelling purulent fluid from the pelvic cavity. Dense interbowel adhesions with multiple loculated pus pockets and flecks of pus scattered throughout the bowel loops were present (Fig. 4). Based on the presence of a foul-smelling purulent collection, appendicular perforation was initially suspected. Therefore, after thorough peritoneal lavage with warm saline and careful adhesiolysis, the bowel was examined systematically from the duodenojejunal flexure to the ileocecal junction. As no perforation was identified and the appendix appeared normal, the stomach and duodenum were explored further, revealing a 1 × 1 cm perforation on the anterior surface of the first part of the duodenum (Fig. 5). Surprisingly, there was no bile-stained fluid or collection in Morrison’s pouch. As the omentum was densely clumped and inadequately vascularized for patch repair, the falciform ligament was mobilized while preserving its hepatic attachment, and a pedicled falciform ligament flap repair was performed (Fig. 6). A pelvic drain was placed intraoperatively and removed on 4th postoperative day. The patient recovered uneventfully, was discharged on 7th postoperative day, and remained well at the 3-month follow-up.

Discussion

Duodenal ulcer perforation most commonly presents as an acute abdomen. Nevertheless, several atypical presentations have been reported. Yanamaladoddi et al. described a case presenting as an anterior abdominal wall abscess [3]. Similarly, Bruner and Gustafson reported a case mimicking acute myocardial infarction [4], while Noussios et al. described Valentino’s syndrome presenting with right iliac fossa pain secondary to a posterior duodenal ulcer perforation [5].

Localized or generalized peritonitis is the typical clinical presentation of perforated peptic ulcer but is present in only about two-thirds of patients [1]. Consequently, physical examination may be inconclusive, with minimal or absent signs of peritoneal irritation (as observed in our patient), particularly in cases of contained or sealed perforation [1]. Crescent-shaped free air beneath the right hemidiaphragm is detected on plain radiography in ~30%–85% of patients with perforated peptic ulcer. This wide range in detection rates indicates that a normal chest or abdominal X-ray does not exclude the possibility of a perforation [1].

The preferred surgical approach for a perforated duodenal ulcer is a supraumbilical midline laparotomy, as performed in our case, because it provides rapid access to the upper abdomen and facilitates thorough exploration of the peritoneal cavity. In most patients, surgery reveals free bilious intraperitoneal contamination due to ongoing leakage of duodenal contents. In contrast, the presence of an intra-abdominal abscess is an uncommon finding (as observed in our case).

Omental patch repair, using either the classical or modified technique, remains the standard surgical approach for duodenal ulcer perforation [6]. However, when the omentum is unavailable or unsuitable for repair because of poor viability, inadequate size, unhealthy tissue, excessive thinness, or prior surgical resection, the pedicled falciform ligament serves as a reliable alternative for defect closure (as done in our case) [7].

Conclusion

Duodenal ulcer perforation may rarely present as a localized intra-abdominal abscess without the classical features of generalized peritonitis or free subdiaphragmatic air. When omental patch repair is not feasible because of dense adhesions or non-viable omentum, a pedicled falciform ligament flap is a safe and effective alternative.

Acknowledgements

Special thanks to the nurses, staff, and doctors who were directly or indirectly involved in the care of the patient.

Conflicts of interest

The authors declare that there is no conflict of interest regarding the publication of this paper.

Funding

None declared.

Data availability

Curated data that were analyzed are available from the corresponding author on reasonable request.

Ethical approval

Ethical approval by the ethics committee is not required for a case report in our country.

Informed consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Provenance and peer review

Not commissioned, externally peer-reviewed.

References