Giant second part of duodenal perforation: Case report and management challenge

Abstract

INTRODUCTION AND IMPORTANCE: Duodenal perforation poses a significant global health challenge, contributing substantially to morbidity, mortality, and hospitalizations. While most perforations occur in the first part of the duodenum, are typically small, and affect older individuals, giant perforations in the second part of the duodenum are exceedingly rare. CASE PRESENTATION: A 20-year-old male patient presented with a three-day history of diffuse abdominal pain, accompanied by nausea, vomiting, and anorexia of similar duration. The physical examination revealed PR = 104, BP = 110/70 mmHg and diffuse abdominal tenderness. A significant intraoperative finding was a 5 × 6 cm perforation in the second portion of the duodenum, with leakage of gastrointestinal and biliary contents consistent with biliary peritonitis. A pyloric exclusion, retrocolic gastrojejunostomy, and duodenal repair were performed. CLINICAL DISCUSSION: Perforations in the second part of the duodenum are considerably rarer. However, when perforation does occur, particularly in the second part of the duodenum, management presents significant challenges, often associated with high rates of morbidity and mortality. Our patient presented with one the high-risk factors-delayed presentation-and, based on established risk stratification models, would therefore carry an estimated mortality risk of approximately 10 %. There is currently a paucity of definitive guidelines or strong expert consensus regarding the optimal surgical approach for giant duodenal perforations located in the second part. In our patient's case, we performed a repair of the perforation, pyloric exclusion, and retrocolic gastrojejunostomy. CONCLUSION: Perforation of the second part of the duodenum is a rare occurrence and presents significant management challenges in emergency situations.