S2873 Abdominal Abscess Formation After Repair of Perforated Duodenal Ulcer

Abstract

INTRODUCTION: Peptic ulcer disease is the most common cause of gastrointestinal perforations, with duodenal ulcers causing 2 to 3 times more perforations than gastric ulcers. The most common causes of peptic ulcer perforation are H. pylori infection and chronic NSAID use. Abdominal abscess, a known complication of subclinical perforated ulcers, is often detected prior to or at the time of diagnosis. We present a case of abdominal abscess formation as a complication after repair of perforated duodenal ulcer. CASE DESCRIPTION/METHODS: A 72-year-old male with history of CAD presented with severe, sudden onset, epigastric pain with nausea and vomiting after ingesting a pill. On admission, vitals were normal. Labs were significant for WBC 15,700 with normal lactic acid and lipase. CT abdomen/pelvis was concerning for perforation. He underwent emergent ex-lap with repair of a perforated post-pyloric duodenal ulcer with drain placement. 4 days later, he endorsed worsening abdominal pain and was found to have two large communicating abdominal abscesses (perihepatic, anterior abdominal) on CT [figures A and B]. Contrast extravasation was seen from the duodenal ulcer to the anterior abdominal abscess [figure A]. A drain was placed into the perihepatic abscess with fluid culture growing Candida albicans. After drain removal, repeat CT revealed resolving perihepatic abscess but enlarging anterior abdominal abscess [figure C], suggesting spontaneous closure between the two, for which an additional drain was placed. He completed a course of Cefepime, Metronidazole and Fluconazole and was started on quadruple therapy for H. pylori. After 4 days of bowel rest, he was successfully started on a diet after upper GI series revealed no contrast extravasation. DISCUSSION: Peptic ulcer perforation should be suspected in patients with sudden onset, severe, diffuse abdominal pain. Emergent surgery is indicated once perforation is identified on imaging. All patients with perforated ulcers should receive aggressive acid suppressive therapy with high dose PPI and evaluation of H. pylori. Empiric treatment for H. pylori remains controversial for perforated ulcers. However, if confirmed, its eradication significantly reduces ulcer recurrence and complications such as reperforation. Our case demonstrates the importance of continued monitoring for abdominal abscesses after surgical repair. Worsening pain may indicate abscess formation, which warrants further imaging and management, such as drainage, stent placement, and/or antibiotics.Figure 1.: Contrast extravasation noted from duodenal ulcer to anterior abdominal abscess.Figure 2.: 19 × 12 × 18 cm Perihepatic abscess (axial and coronal views).Figure 3.: Interval increase in anterior abdominal abscess from 6 × 13 × 18 cm to 8 × 13 × 18 cm (axial and sagittal views).