Asian Journal of Surgery (2015) 38, 239e241

Available online at www.sciencedirect.com

journal homepage: www.e-asianjournalsurgery.com

CASE REPORT

Double peptic perforation: Report of a rarecase

Atul K. Sharma*, Rakesh K. Sharma, Santosh K. Sharma,Devendra Soni, Tej Pratap Singh

Government Medical College and Associated Government Hospitals, Kota, India

Received 17 February 2012; received in revised form 4 March 2013; accepted 3 April 2013Available online 6 June 2013

KEYWORDSdouble pepticperforation;

NSAIDS abuse

* Corresponding author. Midil SchoRajasthan 321203, India.

E-mail address: docatul83@gmail.c

1015-9584/$36 Copyright ª 2013, Asiahttp://dx.doi.org/10.1016/j.asjsur.20

Summary Perforation peritonitis is the most common surgery performed in an emergency.Upper gastrointestinal tract perforation is more common than lower gastrointestinal perfora-tion. Multiple peptic perforations in an individual are a relatively rare entity, with fewer than10 cases reported in the literature. The factor that contributes the most for the occurrence ofmultiple peptic perforations is analgesic and steroid abuse. Herein, we report a rare case ofdouble peptic perforation in a middle-aged man with history of analgesic use for 18 months.Copyright ª 2013, Asian Surgical Association. Published by Elsevier Taiwan LLC. All rightsreserved.

1. Case report

A 42-year-old man presented to the surgical outpatientdepartment of our hospital with a history of abdominalpain, vomiting for 3 days, and constipation and fever for 2days. There was history of sudden pain in upper abdomenfollowed by vomitting. Pain was of severe grade and notrelieved by medication. He had not passed flatus or fecesfor 2 days. He had also had fever with chills for 2 days. Thepatient had significant history of taking nonsteroidal anti-inflammatory drugs (NSAIDs) for toothache for the last 18months. He was a smoker, nondrinker, and vegetarian.

ol Street, Deeg, Bharatpur,

om (A.K. Sharma).

n Surgical Association. Published13.04.001

On admission, he had pallor, tachypnea, tachycardia(110 beats/min), and a fever of 38.5 �C, as well as a rigidabdomen. Guarding and rigidity were present and occasionalbowel sounds were also noted. A flat plate skiagram of theabdomen demonstrated free gas under both hemi-diaphragms. Preoperative investigations demonstratedaltered renal function test (serum urea, 84 mg/L; serumcreatinine, 2.8 mg/dl) and dyselectrolytemia (serum sodium131 meq/L, serum potassium, 2.1 meq/L). The patient wasstabilized hemodynamically and broad-spectrum antibiotics,usually a combination of injectable third generation cepha-losporin and metronidazole, were administered. After initialresuscitation (placement of intravenous lines and nasogastrictube followed by adequate administration of fluids), the pa-tient underwent an emergency exploratory laparotomy.

On exploration, 1500 mL of dirty bilious fluid wereremoved. There was gross peritoneal contamination with

by Elsevier Taiwan LLC. All rights reserved.

240 A.K. Sharma et al.

flakes all over the gut and in the subhepatic region. Afterthorough peritoneal lavage, two gastric perforations wereidentified, one in the prepyloric region ofw0.75 cm� 0.5 cmand anotherw0.5 cm� 0.5 cm was present over the body ofthe stomach along the greater curvature (Fig. 1). Both ofthese perforations were repaired with a 2-0 silk interruptedsuture with omental patch in between (Fig. 2). A 30Fabdominal drain was placed in the pelvis and anatomicalclosure was done in layers. The patient recoveredcompletely and was discharged uneventfully on the 10th

postoperative day.Postoperative gastroscopy revealed erosive gastritis

involving the majority of the greater curvature and pre-pyloric region.

Figure 2 Repairing the perforations.

2. Discussion

Peptic perforation is the most prevalent surgical emer-gency. With high mortality and morbidity, peptic perfora-tion is most commonly present in the first part of theduodenum (35e65%), with 25e45% located in the pylorus,and 5e25% in the stomach.1

The etiological factors responsible for peptic perforationand annual incidence vary depending upon sociodemo-graphic factors,2,3 The factors that contribute the most foroccurrence of peptic perforation are Helicobacter pyloriinfection and chronic use of NSAIDs.4 Gastrointestinalperforation in our region generally occurs as a result ofchronic inflammation due to H. pylori, NSAIDs such asAspirin, stress, excessive smoking, and consumption ofalcohol, coffee, and spicy food. Because these two factors,NSAIDs and H. pylori, produce gastroduodenal injurythrough different mechanisms, they may have additive

Figure 1 Multiple gastric perforations.

effects in terms of producing ulcers. This is quite acontroversial issue, with conflicting results having beenreported as to the presence or absence of such an inter-action. Hawkey suggested that in patients with chronicNSAID use, those who are H. pylori positive are less likely todevelop ulcers, particularly if taking acid-suppressivetherapy.5

We successfully managed a rare and interesting case ofdouble perforation of the stomach. While studying our caseretrospectively we discovered that our patient had beentaking analgesics for toothache for the preceding 18 monthsand was a known smoker. Studies have demonstrated theobvious relationship of analgesic abuse, smoking, andpeptic perforation.6 The occurrence of multiple pepticperforations is a rare entity in which multiple gastric per-forations are further not very common. Multiple pepticperforation reported are due to analgesic (NSAID) or steroidabuse, ZollingereEllison syndrome, burn, postsurgerystress, tubercular stromal ulcer, or Degos disease.7e11 Aftera thorough literature search, only eight cases were found(Table 1). Most of the gastric perforations are located alonglesser curvature while in our case, one was along thegreater curvature and the other in the prepyloric region(Fig. 2).

Gastroscopy performed 6 weeks postoperativelyrevealed erosive gastritis at the greater curvature andprepyloric region. This further confirms the occurrence ofgastric perforation due to NSAID abuse in our case: becauseof gravity, the inciting agents lie on the greater curvatureof the stomach. This explains the development of acutegastritis distally on or near the greater curvature of thestomach in the case of orally administered NSAIDs. Patientswith H. pylori infection are usually asymptomatic but in ourcase, patient who present with upper abdominal pain formore than 6 months with endoscopic finding of lowerabdominal gastritis and from area which are endemic forH. pylori infection are taken as H. pylori Positive. However,we advise all the patients to take H. pylori eradicationtherapy for 2 weeks, especially in tropical countries such asIndia where prevalence of H. pylori infection is very high; itis also the most common etiology for occurrence and

Table 1 Cases of multiple peptic perforation reported in the literature.

Refno.

Author Year Sex Medical history Coexisting disease Condition

10 Kanai M et al 1988 Male Leg pain Degos’ disease Multiple gastric and ileal perforations11 Grigirov et al 1968 Male Steroid therapy n/a Morbid??? Maly L 1996 Male Recurrent pain

abdomenGall bladderperforation

Double gastric perforation withgall bladder Perforation

12 Kuzionov andPolinkova

1973 Male n/a Isolated gastricTuberculosis

Morbid

??? Dahm 1962 Male(4 y)

n/a n/a Multiple duodenal perforation

13 Mynhardat 1951 Male n/a Peptic ulcerdisease with burn

Double duodenal perforation

14 Chaudhary et al 1965 Male n/a n/a Simultaneous multiple peptic peroration15 Akhmedzhanov I

et al1979 Male

(2 mo)Pyloric stenosis Pyloromyotomy

n/a Z not applicable.

Double peptic perforation 241

recurrence of peptic perforation.1,7 A recent study basedon endoscopic findings also confirmed the propensity ofmultiple peptic perforation in NSAID abusers, regardless ofH. pylori infection.12

Increased age, delay in operation, and NSAID abuseadversely affect the operative death rate.13 The best sur-gical option for these patients is simple closure with omentalpatch. It is the easiest, quickest, safest operation, and canbe applied to all situations by every surgeon; moreover, itcan be complemented later with an effective medicaltreatment that should include eradication of H. pylori.

For peptic perforation, a Graham patch repair, with orwithout an acid reducing surgery is probably the mostappropriate management. In our patient we repaired boththe perforation with Graham patch technique and adminis-tered acid suppression therapy postoperatively. Every sur-geon should strictly follow the basic principles for abdominalsurgery. Exploration with thorough peritoneal lavage shouldbe done in every case of perforation peritonitis, even if thepathology appears obvious to avoid missing the rare butimportant possibility of multiple peptic perforations.

3. Conclusion

Multiple peptic perforations are rare but could potentiallybe lethal if missed. One should always keep the possibilityof multiple perforations in mind. Analgesic abuse appearsto be the underlying cause for multiple perforations. Repairof the perforation with Graham patch with acid suppressiontherapy with analgesic (NSAID) avoidance is the treatmentof choice for multiple peptic perforations. Postoperatively,a proton pump inhibitor with anti-H. pylori regimen,especially in tropical countries, should be given to patientswith multiple peptic perforations.

References

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