Background

Perforated duodenal ulcers post-Roux-en-Y gastric bypass (RYGB) are extremely rare, with fewer than 30 documented cases. This abstract presents the case of a 67-year-old female, 24 years post-RYGB, with a perforated duodenal ulcer and pneumoperitoneum.

Methods

The patient had a complex medical history, including a recent ankle injury and NSAID use, and presented with diffuse abdominal pain, fever, hypotension, and tachycardia. The patient's labs were significant for leukopenia and elevated lipase. CT imaging revealed pneumoperitoneum, prompting immediate surgery (Figure 1&2). A 0.5 cm duodenal perforation was repaired with omental plication, and the patient was managed postoperatively for complications, including acute respiratory distress syndrome, bacteremia, and an intra-abdominal abscess (Figure 3&4). Long-term management involved prophylactic H. pylori treatment, long-term antibiotics, proton pump inhibitors (PPIs), and percutaneous drainage of the abscess.

Conclusions

Duodenal perforation post-Roux-en-Y is often challenging to diagnose due to the absence of pneumoperitoneum on CT, seen in only 5 published cases. Due to the rarity of this complication, there is not strong support for a standard treatment, however, omental patch plication is common. The utility of completion gastrectomy for ulcer prevention is debated, considering the associated risks of dysmotility, bacterial overgrowth, and recurrent ulceration of the duodenal stump. The theories regarding the etiology of these ulcers are continued acid production in the remnant stomach and/or Helicobacter pylori infection. The role of NSAIDs in these duodenal perforations remains unclear. Lifelong PPI use and monitoring for recurrent ulcers constitute long-term patient management.