Natural orifice endoscopic drainage of a perforated duodenal ulcer

Abstract

Posterior perforation of gastric and duodenal ulcers is uncommon and frequently misdiagnosed due to nonspecific clinical exam findings. The need for surgical treatment has recently been questioned in patients with contained perforations due to the success of nonoperative management and the morbidity and mortality associated with surgical intervention. We present a clinically stable 65-year-old morbidly obese female transferred to our institution with radiographic evidence of posterior perforation of a duodenal ulcer with a large associated abscess cavity. A fenestrated 9.5 French nasal feeding tube was directed over a guide-wire into the abscess cavity under endoscopic/fluoroscopic guidance and used for decompression. The patient was managed conservatively and repeat computed tomography (CT) demonstrated resolution of the cavity. She was discharged to home after an uncomplicated 10-day hospital course. Contained posterior peptic/duodenal ulcer perforations associated with an abscess cavity can be successfully managed conservatively in patients that are hemodynamically stable and without overt signs of peritonitis. Natural orifice drainage of the cavity, gastric decompression, antibiotics, PPI administration, and nutritional support can avoid the morbidity and mortality associated with traditional surgical management.