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SURGEONS IN TRAINING STILL NEED TO MANAGE THE NATURAL HISTORY OF UNTREATED PEPTIC ULCER DISEASE
Anne M. Montal
*, Miriam Steinberger, Jay Liu, Kelsey McKenna, Hansea Kim, John C. Mcauliffe
General Surgery, Montefiore Medical Center Jack D Weiler Hospital, New York, NY
Here, we report a case of acute posterior gastric perforation in the setting of a longstanding, non-healing, pre-pyloric gastric ulcer, without exacerbating risk factors, in association with a large hiatal hernia, resulting in mediastinal purulence and peritonitis.
During the workup of +stool guaiac 20 years ago, an 85-year-old female with a history of GERD underwent an endoscopy revealing an H. pylori-negative "giant pre-pyloric ulcer." Three months later, a repeat endoscopy demonstrated an improved but persistent large ulcer. The biopsied edges ruled out malignancy. The patient was lost to follow-up.
She presented with acute, sharp epigastric pain. Cross-sectional imaging revealed a foci of extraluminal free air adjacent to a markedly thick-walled distal stomach with surrounding inflammatory changes and a focus of extraluminal air adjacent to the hiatal hernia concerning for a gastrointestinal perforation.
At emergent exploratory laparotomy, the pars flaccida was noted to be disrupted and there was purulent peritonitis. No obvious anterior perforation was seen. The intrathoracic stomach was manually reduced, and the lesser sac was opened to examine the posterior stomach. A 1mm posterior pre-pyloric perforation leaking gastric contents was found. A distal gastrectomy was performed with a roux-en-y gastrojejunostomy (GJ), GJ feeding tube for enteral feeding and gastropexy, and hiatal hernia repair with a pledgeted suture plication of the crura. A 19F Blake drain was placed. The remainder of her hospital course was uncomplicated. Pathology demonstrated chronic gastritis with ulceration and intestinal metaplasia without dysplasia or malignancy and H. pylori-negative.
PUD can lead to malignancy, perforation, and surgical emergencies. With proton pump inhibitors initiated in 1988, the incidence of gastric and duodenal perforations has been greatly reduced from 7.8 and 6.4 per 100,000 person-years to 3.5 and 2.3, with a lifetime prevalence of 5%, and average 30-day mortality of 23.5%. Although perforation is less common than bleeding, it remains the most common indication for emergency surgery and causes approximately 40% of all ulcer-related deaths. Appropriate follow-up and patient education are key to monitoring ulcer progression and preventing complications. Gastric perforations are usually anterior. Posterior gastric perforation is a rare condition; less commonly presenting with peritonitis due to the gastric contents being confined to the lesser sac. It is a surgical emergency with significant morbidity and mortality requiring a high index of suspicion for appropriate intervention to be initiated promptly. This case required addressing multiple complexities in the management of untreated PUD, stressing the importance of the surgical management of PUD in the context of PPIs and in those not treated with PPIs, as well as those with large hiatal hernias.
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