Duodenal Perforation

Anatomically the duodenum is part of the gastrointestinal tract between the stomach and small intestine. It includes four segments:

1. The proximal segment is known as a duodenal bulb, which connects to the liver via hepatoduodenal ligament containing the hepatic artery, the portal vein, and the common bile duct.

2. The second or descending segment is surrounding the pancreatic head.

3. The third segment is the horizontal part. The superior mesenteric vessels are ventral to this segment.

4. The fourth segment follows the jejunum.

Duodenal perforation is a rare but lethal condition. The mortality rate ranges reported from 8% to 25% in the literature. In 1688, the perforated duodenal ulcer was described by Muralto and reported by Lenepneau. Subsequently, in 1894, Dean reported the first case, which successfully underwent surgical closing of a perforated duodenal ulcer. In 1929, Cellan-Jones described a technique for repairing perforations by using an omental, and later in 1937, Graham has modified that technique. Duodenal perforation can either be free or contained. Free perforation arises when bowel contents leak freely into the abdominal cavity and causing diffuse peritonitis. Contained perforation occurs when the ulcer creates a full-thickness hole, but free leakage is prevented by contiguous organs such as the pancreas that wall off the area. Peptic ulcer disease is a significant cause of duodenal perforation. Typically, patients with duodenal ulcers have nocturnal abdominal pain or feel hungry. If perforation occurs, it usually can cause sudden onset of severe pain in the upper abdomen. However, in immunocompromised or elderly patients, the clinical signs can be undetectable and delay diagnosis. Imaging has an essential role in diagnosis, and subsequently, for early resuscitation. Appropriate selection of therapeutic alternatives and risk-assessment can decrease the risk of morbidity and mortality.