Perforation of the gallbladder in association with acute perforated duodenal stress ulcer

Abstract

The association of a perforated gallbladder and bile peritonitis with an acute perforated duodenal stress ulcer is a most unusual circumstance. An 1 I-mo-old white male was admitted to the hospital because of dehydration after a 5-day illness characterized by vomiting and diarrhea, and diagnosed as ordinary viral enteritis. The child appeared moderately ill, and intravenous fluids were begun. After 6 hr. the condition had markedly deteriorated and the appearance seemed to be as one gravely ill. The child was unresponsive, anuric. and hypotensive. The abdomen was distended and tense and no bowel sounds were heard. Vigorous fluid therapy was given for shock, and clinical improvement occurred. About the umbilicus there was a definite bluish discoloration, a very positive Cullen sign. The films of the abdomen showed free air in the peritoneal cavity (Figs. I and 2). Because of the free air and the discoloration of the umbilical skin, the preoperative diagnosis was a strangulated small-bowel obstruction with perforation. At operation a perforated acute duodenal ulcer was found-~ a I-cm perforation on the anterior wall of the bulb just distal to the pylorus. There was also a posterior ulcer. In the ampulla of the gallbladder in juxtaposition to the perforated duodenal ulcer. there was a I-cm perforation and there was, about 500 cc of bile-stained fluid in the peritoneal cavity. A cholecystectomy was requtred for the perforation of the gallbladder. The perforation of the duodenum was closed transversely in two layers The recovery was satisfactory without complication, and the child has remained well.