S3029 A Subtle Presentation of Duodenal Perforation in a Patient with Prior Roux-En-Y Gastric Bypass

Abstract

Introduction: Bariatric surgery is widely used for the management of obesity. Patients with Roux-En-Y Gastric Bypass can develop peptic ulcer disease of the remnant stomach. Peptic ulcer perforation presents as acute abdomen, and free peritoneal air on imaging studies confirms the diagnosis. We discuss a case of perforation of the excluded duodenum in a patient with prior gastric bypass, with subtle clinical presentation of acute pancreatitis and absence of pneumoperitoneum on computerized tomogram (CT) scan of abdomen. Case Description/Methods: A 37 year-old female with no co-morbid conditions presented to our emergency room with a 8/10 intensity epigastric abdominal pain for 4 days, radiating to her back. Her pulse was 96 beats per minute , blood pressure of 108/72 mm of Hg, and epigastric tenderness on abdominal exam. Patient is a smoker and reports 5 to 9 alcoholic drinks per week . Denies NSAIDs use. She had Roux-En-Y Gastric Bypass surgery in 2011, with 100 lbs weight loss . She had cholecystectomy for acute cholecystitis in 2015. Laboratory parameter at presentation revealed total bilirubin levels of 1.6 mg/dl with predominant direct, ALT of 131 IU/dL, serum lipase of 1523 IU/dL. She had CT scan of abdomen that revealed fat stranding in vicinity of pancreatic head with small amount of free fluid (Figure 1A). She was managed as alcohol induced acute pancreatitis and planned for the magnetic resonance cholangiopancretiography (MRCP). Her clinical condition deteriorated over course of 48 hours requiring intensive care monitoring. Abdominal exam revealed peritoneal signs. Repeat CT scan of abdomen revealed large volume ascites with no free peritoneal air and absence of extravasation of the oral contrast (Figure 1B). A diagnostic aspiration revealed fluid lipase of 19264 U/L and, bilirubin of 11 mg/dL. She underwent exploratory laparotomy with drainage of 5 liters of biliary fluid from peritoneal cavity. Kocherization of duodenum revealed a 7 mm perforation in lateral wall of duodenum. Discussion: Absence of pneumoperitoneum on imaging studies can deceive the diagnosis of perforated peptic ulcer in patients with gastric bypass. Ingested air flows through gastrojejunostomy and bypasses remnant stomach. Worsening ascites with high bilirubin levels in aspirated fluid and the worsening clinical condition should raise suspicion for peptic ulcer in remnant gastro-duodenal area.Figure 1.: A. CT Abdomen at presentation showing peripancreatic stranding. B. CT Abdomen at 72 hours showing new onset ascites.