Perforated marginal ulcer following Whipple procedure: A case report
Abstract
Marginal ulcers are rare complications of pancreatoduodenectomy. Patient
can present with varying symptoms such as epigastric discomfort, pain,
dysphagia, or can land in emergency with complications like bleeding and
perforation.
Introduction
Whipple procedures are performed for variety of benign and malignant
lesions affecting the pancreatic head, duodenum, and distal bile
duct.1 Marginal ulcer, one of the rare long term
complications of pancreatoduodenectomy, are ulcerations that occur at or
around the gastrointestinal anastomosis.2 Their
associated morbidity and mortality have been infrequently described in
literature.3 Here we present a case of a gentleman
with a 6 year old history of Whipple procedure who presented in
emergency department with acute onset abdominal pain and was later
diagnosed with perforated marginal ulcer.
Case presentation
A 64-year-old retired soldier who underwent the Whipple procedure six
years ago for carcinoma head of pancreas, adenocarcinoma
(well-differentiated adenocarcinoma) presented to emergency department
with complaints of severe abdominal pain for a one day on the day of
presentation. The pain was acute in onset, continuous, non-radiating,
and increasing in severity, which used to be aggravated after ingestion
of food and movement. He had three episodes of vomiting since morning on
the day of presentation. On his past history, he underwent the Whipple
procedure six years ago and has received complete six cycles of
chemotherapy after surgery. He was under irregular follow-ups for past
two years. The patient had no other comorbid illnesses.
On his arrival to the emergency department, his pulse rate was 130beats
per minute, regular; oxygen saturation 85 % on room air; blood pressure
110/70 mm Hg, body temperature 38.7 ◦C, and respiratory rate(RR) 22
breaths/min. On his physical examination, his abdomen was distended with
diffuse tenderness. There was diffuse guarding and rigidity all over the
abdomen. Bowel sounds were absent. Digital rectal examination revealed a
normal sphincter tone with a collapsed rectum and absent fecal stain on
the gloved finger. He was immediately administered crystalloids and
supplemental oxygen at 4 L/min. Nasogastric tube decompression and Foley
catheterization were done. His laboratory parameters showed leukocytosis
with raised amylase. Liver function test revealed total bilirubin 1.80
mg/dL, conjugated bilirubin 0.8 mg/dL and alkaline phosphatase 712U/L.
On radiological examination, supine abdominal X-ray showed prominent
dilated small bowel loops and free gas under right hemi diaphragm
pointing towards hollow viscous perforation (Fig. 1). Ultrasonography of
the abdomen and pelvis was unremarkable with minimal free fluid in the
pelvis.
After an initial fluid resuscitation, an emergency laparotomy was done.
Intraoperatively, The findings were 300 ml of bilious fluid in the
peritoneal cavity and dense adhesion between the small bowel loops and
previous surgical scar. Adhesions were meticulously released and
gastrojejunostomy site perforation was there, which was around 1 cm
Fig.1. A thorough peritoneal lavage was done and the gastrojejunostomy
site perforation was closed with a well-vascularized omental patch after
a biopsy from the ulcer edge. He received Meropenem IV 1 g and
Vancomycin IV 500 mg twice daily along with low molecular weight Heparin
60 mg twice daily the following day. His condition gradually improved
and was discharged on 10th post operative day.