Case Reports

Indian Pediatrics 2002; 39:578-579

Perforated Duodenal Ulcer in a Child

From the Department of Surgery, Guru Teg Bahadur Hospital and Associated University College of Medical Sciences, Delhi 110 095, India.

Correspondence to: Dr Anup Mohta, 28-B, Pocket-C, SFS Flats, Mayur Vihar Phase-III, Delhi 110 096, India.

E-mail: [email protected]

Manuscript received: September 5, 2001;

Initial review completed: October 4, 2001;

Revision accepted: October 29, 2001.

 

Duodenal ulcer disease is a very uncommon disease in children that is reported only when it presents with complications like perforation and hemorrhage. Even in the cases it presents with acute abdomen due to perforation, it is not considered as a possible diagnosis because of low index of suspicion. We report a successfully treated perforated duodenal ulcer in a young child.

A 3-year male child presented to the surgical emergency with 3 days history of pain abdomen, bilious vomiting and absolute constipation. There was history of fever for past 7 days for which he was given antipyretics by the treating physician. There was no past history suggestive of peptic ulcer disease in the patient or the family.

On examination, the child was lethargic, dehydrated and anemic. The child had tachy-cardia and tachypnea. Cardiac examination revealed pansystolic murmur suggestive of congenital cardiac disease. The abdomen was distended, tender to touch and demonstrated guarding and rebound tenderness. Liver dullness was masked and bowel sounds were absent. Rectal examination revealed empty rectum and there was no melena.

The patient was taken up for exploratory laparotomy after resuscitation with a provisional diagnosis of ileal perforation. At surgery, a small perforation was seen in the anterior wall of the first part of duodenum with bilious collection. There was minimum contamination of the peritoneal cavity. Simple closure of the perforation with omental patch was done. Peritoneal lavage was done and abdomen closed with drain in place. The post-operative recovery was uneventful. On the seventh post-operative day the child developed cyanosis that was attributed to congenital cardiac disease. He was diagnosed to have Tetralogy of Fallot and is on follow-up.

Duodenal ulcer is an uncommonly diagnosed entity in children with an incidence of 1.55 cases per year reported in an Indian series(1). Its diagnosis is usually overlooked because of vague and variable symptoms and low index of suspicion on part of the treating physicians(2). Peptic ulcer in children can be primary associated with Z-E syndrome, sickle cell anemia. H. pylori infection(2), blood group O, etc. or secondary to medica-tions like non steroidal anti-inflammatory drugs (NSAID) and corticosteroids(3,4) or physiological stress in burns, head injury, mucosal ischemia, etc. Maudar et al. associate diet as a predisposing factor(1).

Usually the diagnosis of peptic ulcer in children is made due to complications like perforation and hemorrhage(5-8). Very few reports are available regarding the perforated duodenal ulcer in children in literature. The diagnosis of perforated duodenal ulcer is often missed in the emergency setting due to low incidence of peptic ulcer in children and low index of suspicion. Children present late with shock(8) and carry high morbidity and mortality. Though the abdominal X-ray demonstrates pneumoperitoneum, the dia-gnosis of perforated duodenal ulcer is usually made on exploratory laparotomy for peritonitis.

The treatment of perforated duodenal ulcer is surgical repair. Various methods of treatment include simple closure with omental patch, truncal vagotomy and drainage procedure (TVGJ), hemigastrectomy, etc. Although Maudar et al(1) attribute 100% mortality in three infants to simple closure of the perforation and advocate TVGJ as the treatment of choice, we believe that the mortality in their cases was due to delayed diagnosis leading to severe septicemia in young patients. Simple closure of the perforation with omental patch is an adequate procedure in emergency and can be followed up with medical treatment for the peptic ulcer disease after proper evaluation, a view that is shared by other authors as well(4-6).

The case presented highlights an uncommon entity that is often not thought of by the treating physician. Our patient had three risk factors, i.e., congenital cardiac disease and blood group O and intake of NSAID and was successfully treated with a simple procedure.

Contributors: AM conceived and prepared the manuscript and will act the guarantor of the paper. BPG and AG collected the literature and were involved in the clinical management of the patient. UKS reviewed the manuscript.

Funding: None.

Competing interests: None stated.

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2. Roma E, Kafritsa Y, Panayiotou J, Liakou R, Constantopoulos A. Is peptic ulcer a common cause of upper gastrointestinal symptoms? Eur J Pediatr 2001; 160-497-600.

3. Hernandez-Diaz S, Rodriguez AG. Association between nonsteroidal anti-inflammatory drugs and upper gastrointestinal tract bleeding perforation: An overview of epidemiologic studies published in 1990s. Arch Intern Med 2000; 160: 2093-2099.

4. Bickler SW, Harrison MW, Campbell JR. Perforated peptic ulcer disease in children: Association of cortiocosteroid therapy. J Pediatr Surg 1993; 28: 785-787.

5. Tan SH, Joseph VT, Wong HB. Perforated chronic duodenal ulcer in children. Singapore Med J 1984; 25: 187-189.

6. Johnstone JMS, Rintoul RF. Perforated duodenal ulcer in childhood. Br J Surg 1972; 59: 288-289.

7. Kaushal RK, Narang A, Mitra SK, Prasad GR. Perforated duodenal ulcer. Indian Pediatr 1983; 20: 385.

8. Moon D, Weeks D, Burgess B, O’Connor R. Perforated duodenal ulcer presenting with shock in a child. Am J Em Med 1997; 15: 167-169.