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Introduction
We present the case of a 74-year-old female, who presented to our emergency department with a complaint of acute onset of abdominal pain. The abdominal pain was progressive and unremitting for 15 hours, located in mid-epigastric and right upper quadrant, but without radiation. There were no antecedent episodes of abdominal pain, nausea, vomiting or fever and chills. Physical examination showed pain to palpation in the right upper abdomen and arrest of inspiration with palpation. Bowel sounds were present and there were no peritoneal signs on physical examination. The remainder of the examination was only remarkable for orthopedic scars over both hips and the right knee and advanced osteoarthritis changes to the hands.
Real time ultrasound in the emergency department showed a large gallstone that appeared impacted at the neck of the gallbladder and a normal common bile duct. Pre operative laboratory tests: wbc 11.6 (3.4-10.2 K/CMM), hgb 14 (12-17 G/DL), hct 40.9 (37-51 %), MCV 97 (81-97 fL), platelets 264 (130-400 K/CMM), glucose 114 (70-110 MG/DL), creatinine 0.7 (0.8-1.3 MG/DL), BUN 11 (7-18 MG/DL), protein 7.4 (6.3-8.4 G/DL), albumin 4.0 (normal 3.5-5.0 GM/DL), AST 19 (15-37 U/L), ALT 34 (0-65 U/L), alkaline phosphatase 77 (50-136 U/L), total bilirubin 0.7 (0.3-1.5 MG/L), amylase 28 (25-115 U/L) and lipase 221 (114-286 U/L).
Medical History included hypothyroidism, osteopenia, severe osteoarthritis, prior bilateral total hip and right knee replacements. The patient was a non-drinker and non -smoker. Medications at the time of admission included: tramadol HCL 50 mg ½ tablet po bid, prn, alendronate 70 mg 1 po per wk, simvastatin 20 mg 1 po each day, levothyroxine sodium 75 mcg po daily, meloxicam 15 mg po each day.
Clinical Course
The clinical presentation of this patient with acute abdominal pain, fever, leukocytosis and large gallstone on ultrasound was consistent with acute cholecystitis. The patient was taken to the operating room for cholecystectomy. The initial laparoscopic examination of the peritoneal cavity identified a portion of the falciform ligament adherent to the duodenum. This was taken down to permit insertion of trochars needed for cholecystectomy. The gallbladder was identified and noted to be discolored and inflamed. The gallbladder was freed from ligamentous and hepatic attachments, the cystic duct identified, triple clipped, divided and then removed. The area of the falciform ligamentous adherence to the anterior duodenal wall was then carefully examined. The serosal surface of the duodenum appeared to be inflamed and suggestive of ulcer disease, Figure 1. Simultaneous operative endoscopy was then performed identifying a deep ulcer in the duodenal bulb measuring about 1.5 cm in width, Figure 2. Simultaneous laparoscopic illumination of the serosal surface of the duodenum and endoluminal examination of the ulcer demonstrated a diaphanous, yellow base to the ulcer, Figure 3. A segment of omentum was mobilized and secured over the serosal surface of the duodenal ulcer with three laparoscopic stitches, Figures 4A and B. After laparoscopic irrigation, trochars were removed and the case terminated. The patient was then given one dose Unasyn 3 grams and twice daily pantoprazole 40 mg intravenously. The patient’s postoperative course was unremarkable, converted to omperazole 20 mg orally twice a day by the third postoperative day when she was eating a regular diet. Blood test for H. pylori antibody was negative and fasting gastrin hormone test was normal. The pathologic examination of the removed gallbladder showed evidence of acute and chronic cholecystitis with a 1.5 cm gallstone.
At twelve weeks from date of surgery the patient remained without symptoms. Elective EGD was performed and showed complete ulcer healing and no ulceration or stricture formation. Gastric biopsies were negative for H. pylori, by Warthin-Starry silver stain. The patient continued to experience arthritic pain that did not respond to acetaminophen alone and was reluctantly placed on low dose NSAID alternating with acetaminophen. The patient has been maintained on prophylactic omperazole 20 mg daily and at 6 months of follow up is doing well.
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Figure 1 |
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Figure 2 |
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Figure 3 |
Figure 4a |
Figure 4b |
Discussion
In this case report, an elderly women presented with typical signs and symptoms of acute cholecystitis. Had the surgeon not been alert to the inflammatory changes of the duodenum, the penetrating duodenal ulcer would not have been discovered and the patient’s postoperative course could have been complicated by peritonitis or some other serious morbidity. Urgent upper endoscopy with simultaneous laparoscopy confirmed the duodenal ulcer and guided intra-operative management of this penetrating duodenal ulcer with placement of an omental “Graham” patch.1
As seen in our patient, the dissociation of symptoms is a hallmark of NSAID ulcers. About half of NSAID ulcer complications manifest without heralding symptoms that are recognized by the patient or physician.2 Prospective endoscopic studies of persons who take NSAID’s indicate that ulcer prevalence ranges from 10-20% in the first 3 months use for new gastric ulcers and 4-10% for duodenal ulcers. NSAID- related ulcer risk varies according to dose, duration and type of NSAID.3 According to prospective data from the Arthritis, Rheumatism, and Aging Medical Information System (ARAMIS), 13 of every 1000 patients with rheumatoid arthritis who take NSAID’s for one year have a serious gastrointestinal complication. The risk in patients with osteoarthritis is somewhat lower (7.3 per 1000 patients per year).4 Additional risk factors for NSAID ulcer complications include age > 60yrs, co-administration of anticoagulants, steroids or aspirin.5 The association between NSAID ulcers and infection with H. pylori is controversial, but most recommend habitual NSAID users be treated for H. pylori when infection is identified.6,7 The recent cardiac safety concerns of selective COX-2 inhibitors has further clouded the selection of medications in arthritis patients.8,9
Growing surgical expertise with laparoscopic techniques have lead to the suggestion that laparoscopic closure compares favorably to open surgical techniques for perforated duodenal ulcers.10,11,12 The laparoscopic approach to the management of the penetrating duodenal ulcer seen in this case proved to be ideal, allowing for short postoperative recovery and early hospital discharge.
Disclaimer: The opinions and assertions contained herein should not be considered to reflect the opinions or assertions of the United States Army or the Department of Defense.
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