Acute perforation at the anastomotic site of gastro-jejunostomy for peptic ulcer

INTRODUCTION

Direct exposure of gastric acid is prime cause of ulcer formation which may further complicated by NSAID, alchol and smoking. Gastrojejunal stomal ulcer commonly occur on the jejunal side of the stoma such type of patients usually present with upper GI bleeding, stenosis and acute perforation which is rare^1,2

CASE REPORT

A 55-year-old male, chronic smoker and chronic alcoholic, presented with pain in right iliac fossa with an episode of vomiting and slight abdominal distension for one day. There was no history of trauma, fever and chest pain. Eight years before, he had undergone laparotomy for gastric outlet obstruction secondary to peptic ulcer disease. 6 years back he underwent open pyelolithotomy for left renal calculi and 5 years back for right renal calculi.

On admission, temperature was 99⁰F, pulse 100/min., respiration rate 20/min and blood pressure 110/70 mmHg.

On examination, there was a vertical upper midline scar mark of previous gastroejunostomy surgery. An oblique scar of 8 cm is present in left loin and 5 cm scar perpendicular to line joining the ASIS and umbilicus. Movements of all qudrants of abdomen is diminished and respiration is mainly thoracoabdominal.

Mild abdominal distension is present. Hernial orifices are free.

On Palpation, abdomen is tender with muscle guarding, rigidity and rebound tenderness.

Liver dullness is obliterated. Bowel sounds were absent. Hernial orifices and genitalia were normal.

Per rectal examination was normal.

Xray erect abdomen showed free gas under the right dome of the diaphragm

Ultra Sound Of Abdomen showed distended bowel loops and free fluid in the peritoneal cavity.

The patient was put on continuous Ryle’s tube suction. Intravenous fluid resuscitation along with antibiotic coverage was given.

Exploratory laparotomy was done. On exploration, there was a large collection of fluid in the peritoneal cavity which was cleared with suction. After thorough peritoneal lavage, On clearing the field, a 1cm x 1cm perforation was identified at the jejunal side of the anastomosis of the old retrocolic gastrojejunostomy (Figure 1). The margins were freshened up and primary repair of perforation was done and reinforced with omentum. 28 FG Abdominal drains were placed and abdomen closed in layers. Patient was put nill by mouth and ryles tube aspiration was done for 3 days. Bowel sounds started on 3^rd postoperative day and liquid diet allowed on 4^th post-operative day and he tolerated well. On day 6 patient passed stools and abdominal drains were removed. Successful discharge on day 10.

DISCUSSION

Previously vagotomy and gastro jejunostomy or pyloroplasty were the treatment for peptic ulcer disease. Laparotomy and closure of perforation with omental patch repair still remains the treatment of choice for perforated peptic ulcer. The numbers of vagotomy and astrojejunostomy have been reduced due to success of medical treatment for H. pylori patients with gastrojejunostomy are expected to have complication like hemorrhage, perforation, retrograde intussusception, retroanastomotic hernia and adhesions. The gastrojejunal ulcer may manifest by hemorrhage and shortly afterwards by perforation. We would like to stress that such recurrence of ulcer on the anastomotic site of GJ is common but jejunal side perforation is very rare and seldom reported in the available literature.

Kalaiselvan et al reported the incidence of 1 in 120 patients who underwent laparoscopic Roux-en-Y gastric bypass for morbid obesity.³

Toland and Thomson, in a review of literature, reported the incidence of acute perfotation of gastro-jejunal ulcer to be less than 1 percent.⁴

Chittora reported a case of acute perforation on the efferent loop of the jejunum, close to the anastomotic site.⁵

A case of GJ anastomotic site perforation on jejunal side was reported by Muthukumaran Rangarajan laproscopically.⁶ The gastrojejunal ulcer manifests itself first by hemorrhage and shortly afterwards by perforation.⁷

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

REFERENCES

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