Undercover Ulcers: The Misleading Presentation of Duodenal Bulb Perforation as Pancreatitis

Document Type

Conference Proceeding

Publication Date

10-1-2024

Publication Title

Am J Gastroenterol

Abstract

Introduction: Duodenal ulcers and acute pancreatitis (AP) are common gastrointestinal diseases. AP can result from various factors, including cholelithiasis and alcoholism, and, rarely, from duodenal ulcer perforation (DUP). We report an 83-year-old woman with AP due to a large duodenal ulcer perforation extending into the pancreas, requiring emergent surgery. Case Description/Methods: An 83-year-old woman with Alzheimer's disease, osteoarthritis, and hypertension presented with worsening abdominal pain over 2-3 weeks, with no associated symptoms. Her home medications included aspirin, lisinopril, meloxicam, and donepezil. On presentation, she displayed normal vital signs. Physical examination revealed signs of dehydration and asthenia, with right upper quadrant and epigastric tenderness. Laboratory results indicated hyponatremia, elevated BUN and creatinine, anion gap metabolic acidosis, elevated lipase (1263 U/L), and leukopenia. An electrocardiogram showed sinus tachycardia. Intravenous fluids, morphine, bowel rest, and pantoprazole were started considering it as a case of AP. A computed tomography abdomen with contrast could not be performed initially due to acute kidney injury. Abdominal ultrasound revealed cholelithiasis without cholecystitis. Eventually, the patient developed hypoxia and was put on 4L oxygen. A chest X-ray revealed air under the diaphragm, prompting urgent surgical consultation. The patient went into cardiac arrest shortly but was successfully resuscitated. Following intubation, a computed tomography scan revealed free intraperitoneal air, leading to an urgent exploratory laparotomy. A 4 cm perforation was seen in the duodenal bulb with erosion into the anterior pancreas. Antrectomy and Roux-en-Y gastrojejunostomy were performed. Postsurgery, she was administered antibiotics resulting in improved lactate and lipase levels. Discussion: In this case, our patient initially presented with vague AP symptoms like epigastric pain, lethargy, and anorexia. Her rapid respiratory decline led to a chest X-ray, revealing air under the diaphragm. This case shows that physical exams can be nonspecific for DUP causing AP, especially in older adults. DUP should be considered in acute epigastric pain, particularly in patients with a history or risk factors of peptic ulcer disease (e.g., nonsteroidal anti-inflammatory drug use for osteoarthritis). Her renal dysfunction delayed a computed tomography scan and the DUP diagnosis that led to her decompensation. Therefore, it is crucial to rule out peptic ulcer disease in adults with risk factors when no clear trigger for AP is found to prevent morbidity and mortality (see Figure 1).

Volume

119

Issue

10

First Page

S3006

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