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\begin{document}

\title{Simultaneous Occurrence of Perforated Peptic Ulcer and Acute
Pancreatitis: A Case Report}



\author[1]{Dorsa Shirini}%
\author[2]{Hossein Torabi}%
\author[2]{Rona Ghaffari}%
\affil[1]{Shahid Beheshti University of Medical Sciences}%
\affil[2]{Guilan University of Medical Sciences}%


\vspace{-1em}



  
  \date{May 05, 2024}


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\selectlanguage{english}
\begin{abstract}
Acute abdomen is a life-threatening condition caused by different
incidences such as perforated peptic ulcers and acute appendicitis. This
critical condition needs urgent investigation and treatment. The main
diagnostic ways for acute pancreatitis are clinical examination and
findings. It is essential to consider these two conditions in a patient
simultaneously.%
\end{abstract}%



\sloppy


\textbf{Introduction:}

Acute abdomen is an urgent situation that can be caused by an incidence
of conditions like perforated peptic ulcer and acute pancreatitis
{[}1,2{]}. As a result of the importance of this condition, it needs
rapid intervention and treatment {[}1{]}. Perforation of the peptic
ulcer (PPU), which is an insultaition to the mucosa of the upper tract
of the digestive system, is the second most common complication of the
disease, with the incidence 4 to 14 cases per 100,000 individuals
{[}1,3,4{]}. Acute pancreatitis (AP) is also a common cause of
admissions to the emergency ward, rising in incidence through the last
years,that ranges from 13 to 45 per 100,000 population-years {[}5,6{]}.
Although many underlying risk factors can lead to AP, cholelithiasis and
massive alcohol consumption are two main causes {[}7{]}. This case
presents an individual who was admitted to the hospital complaining of
acute abdominal pain, and after further investigations, he was diagnosed
with concurrent perforated peptic ulcer and acute pancreatitis.

\textbf{Case Presentation:}

The patient was a 71-year-old man who presented to an educational
hospital, Poursina Medical Center, in Rasht, Guilan, Iran, in February
2022, with the chief complaint of abdominal pain. The pain started the
day before. It was periumbilical, was not positional, and was not
contributed to the feeding or defecation. In the beginning, it was
intermittent, and then it developed to be persistent. He did not give a
history of nausea and vomiting. The patient had a past medical history
of hypertension (HTN) and an old cerebrovascular accident (CVA). His
past drug history was unrevealing. On arrival, he had normal vital
signs: a pulse rate (PR) of 78, respiratory rate (RR) of 13, blood
pressure (BP) of 100/40, and he was not febrile (Temperature (T)= 37.2).
On physical examination, the inspection was normal, the bowel sounds
were decreased on auscultation, and there was a generalized tenderness
in palpitation, with the dominance of the epigastric area. A positive
rebound test was also detected on the epigastric area, which favored the
acute abdomen. The patient was asked to do an up-right chest and supine
abdominal X-ray, which didn't show any specific changes, as can be seen
in figures 1and 2. The abdominal ultrasonography was also done. It
revealed free fluid in the pre-splenic and sub hepatic spaces and
Morrison's pouch. A thorough blood exam was done on the arrival date
(Table 1). The rise in the level of pancreatic enzymes (amylase=2320 and
lipase=1854), c-reactive protein (CRP=72), and creatine phosphokinase
(CPK=631) all were in favor of the incidence of acute pancreatitis. Due
to the positive acute abdomen, generalized tenderness in physical
examination, the patient underwent laparotomy. A sealed-off, 1cm*1cm pre
pyloric perforated peptic ulcer was seen with localized debris and free
fluid in the epigastric area. Debris was cleaned out, gastrorrahphy and
omental patch were done, and the abdominal incision was closed. The
patient was hospitalized for ten days. 4 days after the surgery, he was
NPO and treated with intravenous liquids. After that, he started to eat
food and got PO, and was under control. After five days, due to the
decreasing pattern of pancreatic enzymes, as can be seen in table 2, and
the stable clinical condition of the patient, he got discharged.

\textbf{Discussion:}

Acute abdomen is a critical condition caused by various underlying
causes such as infection, inflammation, or vascular problems {[}1{]}.
The condition requires an urgent investigation, including a thorough
examination and treatment based on the physical examination and clinical
findings {[}1{]}. A variety of diseases, including perforated peptic
ulcer (PPU) and acute pancreatitis (AP), can contribute to this
condition{[}2{]}.

Peptic ulcer disease (PUD), which is usually defined as insulation to
the mucosa of the upper digestive tract, most commonly happens in the
stomach and the duodenum {[}3,8{]}. H.Pylori infection and NSAID
consumption are two significant factors leading to PUD {[}3{]}.
Perforation is the second most common complication of the PUD, which
happens in 4 to 14 cases per 100,000 individuals, and the risk increases
with age {[}3{]}. The patient usually presents with the complaint of a
sudden severe epigastric pain {[}3{]}. PPU is divided into four groups
based on its location:\textbf{~} 1. in the antrum, near the lesser
curvature, 2. combined gastric and duodenal ulcer, 3. prepyloric ulcer,
4. ulcer in the proximal stomach or cardia {[}9{]}. The evaluation
consists of a thorough blood test and imaging studies, including an
abdominal and chest x-ray {[}3{]}. Although free air under the diaphragm
is the most common finding in PPU, some studies have shown that it may
be absent in some patients based on the condition of the ulcer {[}10{]}.
The main treatment for PUD is surgical operation {[}3{]}.

Moreover, AP is an inflammation of the pancreas frequently caused by
bile stones or massive consumption of alcohol, which happens in 13 to 45
per 100,000 population years {[}5,6{]}. It is divided into three groups
based on the severity of the disease: 1. Mild: no organ failure, 2.
Moderate: transient organ failure which resolves in less than 48 hours,
and 3. Severe: persistent organ failure that remains more than 48 hours
{[}11{]}. The most common clinical symptom is epigastric pain which
radiates to the back {[}12{]}. A rigorous blood test (including blood
count, lipase, C-reactive protein, glucose, calcium, and liver and
cholestasis enzymes) is mandatory for the diagnosis {[}12{]}. Imaging
tools like CT scans are not usually recommended in patients with typical
clinical manifestations and abnormal laboratory tests {[}13{]}. The
primary treatment strategy is fluid resuscitation between 150 and 250
mL/h in the first 24--48 h, with Ringer lactate as the best choice
{[}12{]}. It is also recommended that oral feeding be encouraged in the
first days of admission if possible {[}14{]}.

In this case report, a 71-year-old patient presented to the hospital
with the chief complaint of sudden epigastric pain from last night.
Although the patient did not have free air under the diaphragm, he
underwent surgery due to the positive acute abdomen on physical
examination. As the PPU was small and sealed off, the absence of free
air on the Xray can be justified. All the debris was washed out with
normal saline, and the perforation was fixed with the gastrorrahphy and
the omental patch. The patient was hospitalized for ten days and treated
for simultaneous pancreatitis with intravenous fluid.

Due to the similar clinical presentation of PPU and AP and the absence
of free air in the X-ray of some patients, which is strongly in favor of
PPU, it is crucial to take both diseases into account for differential
diagnosis of the underlying cause the acute abdomen. Physical
examination and thorough laboratory tests play an essential role in the
diagnosis.

\textbf{Conclusion:}

Acute abdomen is an urgent condition caused by different underlying
conditions like PPU or AP. Because of the same clinical presentation of
both diseases, it is crucial to not only focus on one condition.
Rigorous history, detailed physical examination, and thorough laboratory
tests are needed for the exact approach to the patient. In addition, it
must be remembered that all these conditions can occur simultaneously,
even if they are rare.

\textbf{References:}

{[}1{]} Patterson JW, Kashyap S, Dominique E. Acute Abdomen. 2021 Jul
14. In: StatPearls {[}Internet{]}. Treasure Island (FL): StatPearls
Publishing; 2022 Jan--. PMID: 29083722.

{[}2{]} Elhardello OA, MacFie J. Digital rectal examination in patients
with acute abdominal pain.~Emerg Med J.~2018 Sep;35(9):579-580.

{[}3{]} Stern E, Sugumar K, Journey JD. Peptic Ulcer Perforated. 2021
Jun 23. In: StatPearls {[}Internet{]}. Treasure Island (FL): StatPearls
Publishing; 2022 Jan--. PMID: 30855910.

{[}4{]} 1.~Graham RR, Tovee E.~The treatment of perforated duodenal
ulcers.~\emph{Surgery} . 1945;17(5):704-712.

{[}5{]} Peery AF, Crockett SD, Barritt AS, Dellon ES, Eluri S, Gangarosa
LM, Jensen ET, Lund JL, Pasricha S, Runge T, Schmidt M, Shaheen NJ,
Sandler RS. Burden of Gastrointestinal, Liver, and Pancreatic Diseases
in the United States. Gastroenterology. 2015 Dec;149(7):1731-1741.e3.
doi: 10.1053/j.gastro.2015.08.045. Epub 2015 Aug 29. PMID: 26327134;
PMCID: PMC4663148.

{[}6{]} Ouyang, G., Pan, G., Liu, Q.~\emph{et al.} ~The global,
regional, and national burden of pancreatitis in 195 countries and
territories, 1990--2017: a systematic analysis for the Global Burden of
Disease Study 2017.~\emph{BMC Med} ~\textbf{18,~} 388 (2020).
https://doi.org/10.1186/s12916-020-01859-5

{[}7{]} Krishna SG, Kamboj AK, Hart PA, Hinton A, Conwell DL.~The
changing epidemiology of acute pancreatitis hospitalizations: a decade
of trends and the impact of chronic pancreatitis.~\emph{Pancreas.}
~(2017)~46:482--8. 10.1097/MPA.0000000000000783

{[}8{]} Lanas A, Chan FKL. Peptic ulcer disease.~Lancet.~2017 Aug
05;390(10094):613-624.

{[}9{]} Chernyshev VN, Aleksandrov IK. {[}Classification of stomach
ulcers and choice of the surgery method{]}.~Khirurgiia (Mosk).~1992
Sep-Oct;(9-10):3-8.

{[}10{]} hen CH, Yang CC, Yeh YH. Role of upright chest radiography and
ultrasonography in demonstrating free air of perforated peptic ulcers.
Hepatogastroenterology. 2001 Jul-Aug;48(40):1082-4. PMID: 11490805.

{[}11{]} Lepp\selectlanguage{ngerman}äniemi A, Tolonen M, Tarasconi A, Segovia-Lohse H,
Gamberini E, Kirkpatrick AW, Ball CG, Parry N, Sartelli M, Wolbrink D,
van Goor H, Baiocchi G, Ansaloni L, Biffl W, Coccolini F, Di Saverio S,
Kluger Y, Moore E, Catena F. 2019 WSES guidelines for the management of
severe acute pancreatitis. World J Emerg Surg. 2019 Jun 13;14:27. doi:
10.1186/s13017-019-0247-0. PMID: 31210778; PMCID: PMC6567462.

{[}12{]} Gliem N, Ammer-Herrmenau C, Ellenrieder V, Neesse A. Management
of Severe Acute Pancreatitis: An Update. Digestion. 2021;102(4):503-507.
doi: 10.1159/000506830. Epub 2020 May 18. PMID: 32422634; PMCID:
PMC8315686.

{[}13{]}~Working Group IAPAPAAPG IAP/APA evidence-based guidelines for
the management of acute pancreatitis.~\emph{Pancreatology.~} 2013
Jul-Aug;13((4 Suppl 2)):e1--5.

{[}14{]} Bakker OJ, van Brunschot S, van Santvoort HC, Besselink MG,
Bollen TL, Boermeester MA, et al. Early versus on-demand nasoenteric
tube feeding in acute pancreatitis.~\emph{N Engl J Med.~} 2014
Nov;371((21)):1983--93

Figures:

Figure1. Upright Chest Xray

Figure2. Supine Abdominal Xray

Tables:

Table1.

\textbf{Blood Test}\selectlanguage{english}
\begin{longtable}[]{@{}lll@{}}
\toprule
\textbf{Hematology} & WBC & 6500\tabularnewline
& Neutrophil & 90\tabularnewline
& Lymphocyte & 8\tabularnewline
& RBC & 4.01\tabularnewline
& HB & 11.1\tabularnewline
& Plt & 269000\tabularnewline
\textbf{Biochemistry} & BS & 130\tabularnewline
& BUN & 35\tabularnewline
& Cr & 2.6\tabularnewline
& Alt & 18\tabularnewline
& Ast & 17\tabularnewline
& Alp & 168\tabularnewline
& Total Bilirubin & 2.0\tabularnewline
& Direct Bilirubin & 0.5\tabularnewline
& Amylase & 2320\tabularnewline
& Lipase & 1854\tabularnewline
& Na & 140\tabularnewline
& K & 4.8\tabularnewline
& Ca & 9.7\tabularnewline
& Ph & 3.0\tabularnewline
& Mg & 2.6\tabularnewline
\textbf{VBG} & PH & 7.31\tabularnewline
& PCO2 & 33.2\tabularnewline
& HCO3 & 16.2\tabularnewline
& BE & -9.1\tabularnewline
\textbf{Serology} & CRP & 72\tabularnewline
\textbf{Coagulation} & PT & 15\tabularnewline
& PTT & 38\tabularnewline
& INR & 1.3\tabularnewline
\bottomrule
\end{longtable}

Table2.

\textbf{Blood Test}\selectlanguage{english}
\begin{longtable}[]{@{}lll@{}}
\toprule
\textbf{Hematology} & WBC & 10000\tabularnewline
& Neutrophil & 40\tabularnewline
& Lymphocyte & 58\tabularnewline
& RBC & 3.49\tabularnewline
& HB & 9.6\tabularnewline
& Plt & 401000\tabularnewline
\textbf{Biochemistry} & BS & 102\tabularnewline
& BUN & 28\tabularnewline
& Cr & 1.9\tabularnewline
& Alt & 20\tabularnewline
& Ast & 21\tabularnewline
& Alp & 395\tabularnewline
& Total Bilirubin & 0.6\tabularnewline
& Direct Bilirubin & 0.2\tabularnewline
& Amylase & 530\tabularnewline
& Lipase & 398\tabularnewline
& Na & 152\tabularnewline
& K & 3.6\tabularnewline
& Ca & 8.1\tabularnewline
& Ph & 2.8\tabularnewline
& Mg & 2.3\tabularnewline
\textbf{Coagulation} & PT & 13\tabularnewline
& PTT & 31\tabularnewline
& INR & 1.0\tabularnewline
\bottomrule
\end{longtable}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Upright-chest-X-ray/Upright-chest-X-ray}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Supine-abdominal-X-ray/Supine-abdominal-X-ray}

\end{center}
\end{figure}

\selectlanguage{english}
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