Case Report
Copyright ©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Cases. Sep 6, 2022; 10(25): 9071-9077
Published online Sep 6, 2022. doi: 10.12998/wjcc.v10.i25.9071
Post-bulbar duodenal ulcer with anterior perforation with kissing ulcer and duodenocaval fistula: A case report and review of literature
Nasser Alzerwi
Nasser Alzerwi, Department of Surgery, College of Medicine, Majmaah University, Riyadh 66, Riyadh , Saudi Arabia
Author contributions: Alzerwi N conducted case analysis, literature review, and manuscript writing.
Informed consent statement: A written informed consent was obtained from the patient for publication of this case report.
Conflict-of-interest statement: All the authors have nothing to disclose.
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Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Nasser Alzerwi, MS, Associate Professor, Department of Surgery, College of Medicine, Majmaah University, Ministry of Education, P. O. Box 66, Al-Majmaah City, Riyadh Region 11952, Saudi Arabia. n.alzerwi@mu.edu.sa
Received: April 8, 2022
Peer-review started: April 8, 2022
First decision: May 12, 2022
Revised: May 27, 2022
Accepted: July 25, 2022
Article in press: July 25, 2022
Published online: September 6, 2022
Processing time: 139 Days and 19.1 Hours
Abstract
BACKGROUND

A post-bulbar duodenal ulcer (PBDU) is an ulcer in the duodenum that is distal to the duodenal bulb. PBDU may coexist with a synchronous posterior ulcer in rare occurrences, resulting in a kissing ulcer (KU). Duodenocaval fistula (DCF) is another uncommon but potentially fatal complication related to PBDU. There is limited knowledge of the scenarios in which PBDU is complicated by KU and DCF simultaneously.

CASE SUMMARY

A 22-year-old man was admitted to the emergency department with abdominal pain, stiffness, and vomiting. The X-ray showed pneumoperitoneum, suggesting a perforated viscus. Laparotomy revealed a KU with anterior perforation and a DCF. After Kocherization, venorrahphy was used to control caval bleeding. Due to the critical condition of the patient, only primary duodenorrahphy with gastrojejunostomy was performed as a damage control strategy. However, later, the patient developed obstructive jaundice and leakage, and two additional jejunal perforations were detected. Due to the poor condition of the duodenum and the involvement of the ampulla in the posterior ulcer, neither primary repair nor pancreatic-free duodenectomy and ampulloplasty/ampullary reimplantation were considered viable; therefore, an emergency pancreaticoduodenectomy was performed, along with resection and anastomosis of the two jejunal perforations. The patient had a smooth recovery after surgery and was discharged after 27 d.

CONCLUSION

The timely diagnosis of PBDU and radical surgery can aid in the smooth recovery of patients, even in the most complex cases.

Keywords: Duodenal ulcer; Duodenocaval fistula; Kissing ulcer; Emergency Whipple's surgery; Case report

Core Tip: A post-bulbar duodenal ulcer, in combination with a kissing ulcer (KU) and a duodenocaval fistula (DCF), is a severe complication with a high mortality rate. In the present case, the patient had a KU with anterior perforation and a DCF. After Kocherization, venorrahphy was used to control caval bleeding. The patient, however, later developed obstructive jaundice and leakage. Due to the poor condition of the duodenum and the involvement of the ampulla in the posterior ulcer an emergency pancreaticoduodenectomy was performed, along with resection and anastomosis of the two jejunal perforations. The patient had a smooth recovery after surgery.