CASE REPORT POSTERIOR PERFORATION OF GASTRIC ULCER-A RARE SURGICAL EMERGENCY

Dr. Vijaykumar Kappikeri, Professor Department of Surgery M R Medical College, Gulbarga Abstract: Posterior perforation of gastric ulcer is a rare surgical emergency associated with a high mortality and morbidity. The diagnosis is commonly missed. very few cases have been reported in literature. Here, we report a case of posterior perforation of gastric ulcer which was operated and discharged without any complications. Key words: gastric ulcer;posterior perforation;peptic ulcer perforation .

Introduction: The most common site of peptic ulcer perforation is the anterior aspect of the duodenum. however, the anterior or incisural gastric ulcer may perforate and in addition' gastric ulcers may perforate into the lesser sac, which can be particularly difficult to diagnose. The patients may not have obvious peritonitis.[1] Case report: A 58yr old female was admitted with complaints of pain in abdomen since 5 days, sudden in onset, progressive in nature and distension since 3 days .patient was febrile and vitals were stable. On examination ,abdomen was distended, soft and tender, with absent peristalsis .there was no rebound tenderness. Chest x ray demonstrated pneumoperitoneum and a diagnosis of perforated viscus was made. USG showed fluid filled bowel loops with free fluid in peritoneal cavity. Blood investigations were Hb 11.6gms%,TC10,300CELLS/cumm Blood urea 101 and S.Creatinine1.0 An emergency laparotomy was done .On exploration,moderate peritoneal collection was present which was drained out. No perforation was seen in the anterior surface of stomach or duodenum .Rest of the gastrointestinal tract was normal. A thorough search for site of perforation was done. Bilestaining of greater omentum was noted near greater curvature of proximal part of body of stomach. Gastrocolic omentum was opened and pus drained out from the lesser sac. A 2cm perforation of posterior gastric wall in the body of stomach was noted towards the greater curvature. Fig[1,2,3].Biopsy of the ulcer edge was taken , the perforation was closed with vicryl and an omental patch was applied. Biopsy report did not show any evidence of malignancy.Patient recovered and was discharged after 25 days in the hospital without any complications.

Discussion: While, the incidence of duodenal ulcer disease has decreased in the last few decades , the incidence of gastric ulcer has remained unchanged or has increased slightly .The estimated incidence is approximately 0.3 per 1000 per year, with a peak occuring between the fifth and seventh decades of life. widespread use of non steroid anti inflammatory drugs (NSAIDs) cause injury to the gastric mucosa. The use of NSAIDs is a major precipitating factor in the perforation of gastric and duodenal ulcers.[2].Perforation is the most frequent complication of gastric ulcer. Most perforations occur along the anterior aspect of the lesser curvature.60-70%of gastric ulcers occur on the lesser curvature, at or proximal to incisura. Gastric ulcer located in the proximal stomach or in the gastric cardia is rare in the US or Europe but common in latin america. Larger ulcers are associated with more morbidity and higher mortality rates.[3]. Posterior gastric ulcers may erode into the lesser sac behind the stomach (for gastric ulcers in the fundus or body of the stomach) or the retroperitoneal space (pyloric ulcers).The local inflammatory reaction and fibrosis of the surrounding adherent retroperitoneal tissue contribute to sealing off the perforation. This explains the rarity of this entity and the vague and insidious symptoms that characterise such perforations when they occur .The lesser sac behind the stomach is a potential space and is less effective in sealing off a posteriorly situated gastric ulcer eroding through the wall of the stomach. In contrast, the pyloro-duodenal channel is firmly adherent to the retroperitoneal space and therefore may be less prone to posterior perforations.[4].The clinical presentation is much less dramatic than that of anterior perforations .Delayed presentation is a characteristic of

posterior perforation. Patient complains of gnawing epigastric or hypochondrium pain of variable duration .these perforations are commonly missed on initial examination. Perforated gastric ulcers are much less frequent than perforated pyloro-duodenal ulcers.Gastric perforations are usually larger than duodenal perforations and more common in elderly patients[5]. In a series of 125 consecutive perforated peptic ulcer patients operated by Hamilton Bailey , there was only one case of perfotion on posterior surface of stomach. When perforation has occured into the lesser sac , the fluid pours out of the foramen of winslow.[6]. Posterior perforation is rare with fewer than 30 cases reported in the literature. Chin Ho Wong et al (2003) reviewed 9 patients with posterior perforations who wre treated from Jan 1990 to June 2002.Their findings were sealed perforation, localised retroperitoneal abscess or generalised peritoneal contamination of the lesser sac and peritoneal cavity. Pre existing chronic medical illnesses ,prolonged perforation(>24 hrs), preoperative hypotension,significant peritoneal contamination at celiotomy, major resection (Gastrectomy) and gastric perforations were associated with poor outcome. 4 of the 9 patients died.[7]. Conclusion: Posterior perforation should be suspected when a perforation is not obvious on exploration of abdomen. Check the posterior wall of the stomach by opening the lesser sac. Pneumoperitoneum when present is definite and invaluable sign for evaluation Of patients with posterior perforation. It is also an indication for immediate surgical exploration.

References: 1. Norman Williams, Christopher Bullstrode , Ronan O Connell (2008) stomach and duodenum in Bailey and Love's short practice of surgery 25th edition . Arnold publishers, London . p. 1062 2. Michael Zinner,Seymour Schwartz,Harold Ellis(1997) Maingots abdominal operations .10th edition. Appleton lange .Prentice Hall

International.Inc.USA.pp971,983. 3. David W Mercer,E mily K Robinson(2004)Stomach, in Sabiston Text book of surgery .Courtney M Townsend, R Daniel Beauchamp, Mark evers, Kenneth LM mattox (ED)17th edition. Saunders-Elsevier. USA.p,1279,1284. 4. Chin HO-Wona, Pierce K H Chow.(2004).Posterior perforation of gastric ulcer. Digestive diseases and sciences. vol 49, No 11/12 pp.1882-1883. 5. Thomas B Hugh .(1990)Perforated peptic ulcer. in Maingots abdominal operations.9th edition.Seymour schwartz , Harold Ellis(ed) Appleton & Lange company, USA. 6. B.W.Ellis (1995)Perforated and obstructed peptic ulcer. Hamilton Baileys Emergency Surgery.12th edition. Butterworth Heinemann Ltd.Oxford.pp.359-62. 7. Chin Ho Wong, Pierce K H Chow, Hock soo ong, Weng Hoong Chan, Lay Wai Khin, Khee Chee Soo.(2004).Posterior perforation of peptic ulcers: presentation and outcome of an uncommon surgical emergency.Surgery;135:321-5.

Figure-1: Lesser sac opened to expose the perforation

Figure-2: Showing posterior gastric wall perforation

Figure-3: Lesser sac opened near the spleen