Clin J Gastroenterol (2013) 6:373–377 DOI 10.1007/s12328-013-0417-7
CASE REPORT
Retroperitoneal abscess associated with a perforated duodenal ulcer Ai Sadatomo • Koji Koinuma • Toru Zuiki Alan T. Lefor • Yoshikazu Yasuda
•
Received: 24 June 2013 / Accepted: 19 August 2013 / Published online: 5 September 2013 Ó Springer Japan 2013
Abstract Retroperitoneal abscess after duodenal ulcer perforation is a rare condition. A 71-year-old woman was admitted with 1 month of appetite loss and back pain. Abdominal computed tomography scan showed a retroperitoneal mass behind the third and fourth portions of the duodenum. Single-balloon enteroscopy revealed erosion of the third portion of the duodenum with leakage of contrast agent into the retroperitoneal space. Based on a preoperative diagnosis of retroperitoneal abscess after duodenal perforation, laparotomy was performed. Partial duodenectomy with a duodeno-jejunal anastomosis was performed, and her postoperative course was uneventful. Pathology showed an ulcer with no specific findings. KeyWords Duodenal ulcer Perforation Retroperitoneal abscess
Introduction Perforation of the duodenal bulb due to ulcer disease is common. However, perforation in other portions of the duodenum is rarely due to ulcer disease. If this does occur, the perforation may track toward the retroperitoneal space. We report a case of ulcer perforation in the third portion of the duodenum resulting in a retroperitoneal abscess.
A. Sadatomo (&) K. Koinuma T. Zuiki A. T. Lefor Y. Yasuda Department of Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498, Japan e-mail: [email protected]
Case report A 71-year-old woman visited her local physician with complaints of appetite loss and back pain for 1 month. She didn’t have any history of taking medicine, smoking and alcohol. Abdominal computed tomography (CT) scan revealed a mass near the pancreas. She was referred for further diagnosis and treatment. On admission, her blood pressure was 114/69 mmHg, pulse 82 per minute, and temperature 37.5 °C. Physical examination revealed left upper quadrant tenderness, but no guarding. Blood tests revealed a white blood cell count of 10,900/mm3, platelet count 398,000/mm3, and C-reactive protein of 23.36 mg/dl (Table 1). Abdominal CT scan showed a large mass located behind the third portion of the duodenum with lateral extension to the ligament of Treitz. No free air was seen in the peritoneal or retroperitoneal spaces (Fig. 1). A small amount of ascites was noted in the pelvic cavity. Based on these findings, a retroperitoneal tumor was suspected. Single-balloon enteroscopy was then performed, which showed an ulcerous lesion in the third portion of the duodenum. The ulcer bed was covered with necrotic tissue (Fig. 2). Contrast material leaking from the third portion into the retroperitoneal space was noted (Fig. 2). Biopsy specimen taken from the ulcer lesion was erosive mucosa. These findings were consistent with perforation of the third portion of the duodenum resulting in a retroperitoneal abscess. She was referred to the Department of Surgery, and emergent laparotomy performed. A mass, 15 cm in diameter, behind the third portion of the duodenum was found. The mass was hard with a thickened wall containing purulent material. A 2 cm perforation was identified in the posterior wall of the third portion of duodenum (Fig. 3). Due to marked inflammation of the duodenal wall and
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Table 1 Laboratory data on admission 3
3
WBC
10.9 9 10 /mm
RBC
398 9 104/mm3
CRP
23.36 mg/dl
TP
6.5 g/gl
Hb
9.6 g/dl
Alb
2.7 g/gl
Ht
29.4 %
BUN
14 mg/dl
Plt
39.3 9 104/ll
Cr
0.42 mg/dl
PT-%
79.1 %
AST
86 mU/ml
PT-INR
1.12
ALT
40 mU/ml 264 mU/ml
H.pylori IgG Ab
(-)
LDH
CEA
2.7 ng/ml
Na
135 mmol/l
CA19-9
26 U/ml
K
3.5 mmol/l
Cl
96 mmol/l
surrounding tissues, closure of the perforation was not performed. Duodenectomy of both the third and fourth portions, including the proximal jejunum was performed and reconstructed with a duodeno-jejunostomy. A tube gastrostomy was placed intraoperatively, and a drain was placed into the abscess cavity. The bacteriological culture test on the pus was negative. Her postoperative course was uneventful except for poor gastric emptying, and she was discharged on the 39th postoperative day. Pathological examination of the resected specimen revealed that the cause of the perforation was a simple duodenal ulcer (Figs. 4, 5a, b).
Discussion The etiologies of retroperitoneal abscesses are varied and include perforation of the colo-rectum, infection of the
Fig. 1 CT scan showed an abscess cavity (arrow). No free air was seen in the peritoneal or retroperitoneal spaces
123
urinary tract, pancreatitis, appendicitis and postoperative complications, among others. A retroperitoneal abscess due to perforation of the duodenum is rare. Altemeier surveyed retroperitoneal abscesses treated between 1912 and 1961 at the Cincinnati General Hospital. Of 189 patients with an abscess, only two (0.95 %) originated in a duodenal perforation [1]. The most common reported cause of a duodenal perforation is a diverticulum. Other causes of intestinal ulcer are H. pylori infection, cytomegalovirus infection, tuberculosis infection, Crohn’s disease, drug-induced enteritis, radiation enteritis and foreign body such as a biliary stent, a nasojejunal feeding tube and a fish bone. In our case, there was no evidence of these diseases. A literature search including papers published from 1966 to 2012, showed only 11 cases of retroperitoneal abscess due to duodenal ulcer perforation [2–8] (Table 2). The sites of perforation in the duodenum included: duodenal bulb in two (18 %), the second portion in two (18 %), the third portion in one (9 %), and unknown in six (55 %). The most common symptom in patients with retroperitoneal perforation of the duodenum is epigastric and right upper quadrant pain. Other symptoms include nausea, vomiting and fever. Sign of peritonitis are rare in this condition. In the present case, the patient’s symptoms were appetite loss and back pain lasting for 1 month, which had not been getting worse. The clinical presentation varies greatly and requires a high index of suspicion. Radiologic imaging has been regarded as a useful tool to establish the diagnosis of a retroperitoneal abscess. In most patients (7/11, 64 %), there was a normal gas pattern on
Clin J Gastroenterol (2013) 6:373–377
375
Fig. 2 Single-balloon enteroscopy showed an ulcerous lesion covered with necrotic tissue in the third portion of the duodenum (White arrow). Contrast material leaked from the third portion into the retroperitoneal space (Black arrow)
Fig. 3 An intraoperative photograph showed a large perforation in the posterior wall of the third portion of the duodenum (arrow)
abdominal X-ray. However, CT scan can detect small amounts of gas and/or fluid in the retroperitoneal space. CT scan offers a standard for establishing the diagnosis of retroperitoneal abscesses and determining their anatomic extent [9]. However, in the cases reported, an accurate preoperative diagnosis was made in only three patients (3/ 11, 27 %).
Fig. 4 Resected specimen: excised duodenum was divided into two parts. Perforation sight was detected in the third portion of the duodenum (arrow)
Enteroscopy involves use of a video enteroscope for direct visualization of the small bowel. This procedure allows identification of intra-luminal abnormalities, such as tumor, ulcer, diverticulum and foreign body [9]. Leakage of contrast agent on X-ray during enteroscopy is evidence of an intestinal perforation. Both in the present patient and Patient #7 (Table 2), the radiographic contrast study supported a firm preoperative diagnosis of duodenal
123
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Fig. 5 A high power view of the perforation site (arrow) showed necrotic tissue with inflammation cells infiltration. There was neither foreign body nor tumor. a (HE staining 910), b HE staining 920
perforation. To limit the extent of surgical intervention, an accurate preoperative diagnosis is very important. Among previously reported patients who died (Patients 2–7, Table 2), death was due to sepsis, pneumonia, and pulmonary embolism. However, the mortality rate has decreased, with the use of appropriate surgical drainage, improvements in perioperative care and the development of broad-spectrum antibiotics [10]. Surgical treatment was performed in all patients reported. The optimal surgical procedure varies, and depends on both the patients’ general condition and operative findings. Direct closure of the perforation site with omentopexy and drainage may be possible when intra-abdominal inflammation is mild and the perforation is small. When inflammation is severe or the site of perforation is not small, digestive tract diversion such as pyloric exclusion with a Billroth-II reconstruction or tube gastrostomy should be used to minimize the risk of leakage at the site of perforation. In the present patient, inflammation of the third and fourth portions of the duodenum was severe, but the second portion was not inflamed, allowing safe conduct of an anastomosis between the second portion and the jejunum. To allow adequate decompression of the anastomotic site in the postoperative period, a gastrostomy was placed. A perforated ulcer in the third portion of the duodenum with formation of a retroperitoneal abscess is a rare entity, and is occasionally difficult to diagnose. Enteroscopy is a helpful tool to establish the diagnosis. Optimal surgical therapy should be performed based on the individual patients’ condition and operative findings.
Table 2 Cases of retroperitoneal abscess from duodenal ulcer perforation Patient No
Author
Years
Age
Sex
Complaints
Chest X-ray findings
Preoperative diagnosis
Site of perforation
Treatment
Outcome
1
Britt
1966
62
M
Epigastric pain
Non-specific
Perforation of appendix
Drainage, duodenostomy
Alive
2
Hashmonai
1971
58
F
F
4
48
M
Drainage, transverse loop colostomy Drainage, appendectomy Drainage
Died
64
Distended loops of colon, ileus of bowel –
Perforation of colon
3
5
75
M
Fever, apptite loss Abdominal patin Abdominal patin, vomit –
Posterior wall of bulb Unknown (autopsy)
Drainage, Closure of the perforation
Died
123
Non-specific
Non-specific
Perforation of appendix Duodenal ulcer
Unknown (autopsy) Unknown (autopsy)
Strangulated right inguinal hernia
Third portion
Died Died
Clin J Gastroenterol (2013) 6:373–377
377
Table 2 continued Patient No
Author
Years
Age
Sex
Complaints
Chest X-ray findings
Preoperative diagnosis
Site of perforation
Treatment
Outcome
6
Edmondson
1972
54
M
Abdominal pain, vomit
Density in the right abdomen
Posterior wall
Drainage, Duodenogastric resection, Billroth II reconstruction
Died
7
Catalano D
1984
58
M
Abdominal pain, fever
Nonspecific
Unknown
Drainage, Duodenogastric resection
Died
8
Sturup J
1985
51
F
Abdominal pain
–
Perforation of duodenal or appendix Duodenal ulcer perforation Peritonitis
Posterior wall
Alive
9
Vellar ID
1989
55
F
Abdominal pain
Nonspecific
Pancreatic abscess
10
Wong
2004
40
–
No peritonism
Nonspecific
Perforated viscus
Drainage, Closure of the perforation, gastrojejunal anastomosis Drainage, Closure of the perforation, gastrojejunal anastomosis, jejunostomy, T-tube drainage Drainage
11
55
–
No peritonitis
Nonspecific
Perforated viscus
Present case
71
F
Appatite loss, back pain
Nonspecific
Perforation of duodenal
Disclosures Conflict of Interest: The authors declare that they have no conflict of interest. Human/Animal Rights: All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008(5). Informed Consent: Informed consent was obtained from all patients for being included in the study.
References 1. Altemeier WA, Alexander JW, et al. Retreoperitoneal abscess. Arch Surg. 1961;83:512–24. 2. Britt LG, Wolf RY. Postbulbar ulcer with retrocecal abscess. A case report. Arch Surg. 1966;92(1):98–100. 3. Hashmonal M, Abrahamson J, Erlik D, Schramek A. Retroperitoneal perforation of duodenal ulcers with abscess formation.
4.
5.
6. 7.
8.
9.
10.
Posterior wall of the second portion Posterior wall of bulb Posterior wall of the second portion Posterior wall of the third portion
Drainage, Closure of the perforation, pyloric exclusion, gastrojejunal anastomosis, jejunostomy, Drainage, duodenectomy, duodenojejunostomy
Alive
Alive
Alive
Alive
Report of four cases and survey of the literature. Ann Surg. 1971;173(3):409–14. Edmondson HT, Terry DB Jr. Retroperitoneal abscess from posterior perforation of duodenal ulcer. J Med Assoc Ga. 1972;61(11):374–5. Catalano D, Troianiello B. Left side abdominal abscess from a retroperitoneal perforation of a duodenal ulcer. Rofo. 1984; 141(1):111–3. Sturup J, Raahave D. Retroperitoneal perforation of duodenal ulcer. Ann Chir Gynaecol. 1985;74(6):299–300. Vellar ID, Vellar D. Retroperitoneal perforation of a peptic ulcer situated in the second part of the duodenum. Aust N Z J Surg. 1989;59(7):592–3. Wong CH, Chow PK, Ong HS, Chan WH, Khin LW, Soo KC. Posterior perforation of peptic ulcers: presentation and outcome of an uncommon surgical emergency. Surgery. 2004;135(3):321–5. Dyr CE, Graffiney RR, Dykes TM, Moyer MT. Endoscopic and radiographic evaluation of the small bowel in 2012. Am J Med. 2012; 125(12):1228.e1–e12. Tunguntla A, Raza R, Hudgins L. Diagnostic and therapeutic difficulties in retroperitoneal abscess. South Med J. 2004;97(11): 1107–9.
123
CASE REPORT
Retroperitoneal abscess associated with a perforated duodenal ulcer Ai Sadatomo • Koji Koinuma • Toru Zuiki Alan T. Lefor • Yoshikazu Yasuda
•
Received: 24 June 2013 / Accepted: 19 August 2013 / Published online: 5 September 2013 Ó Springer Japan 2013
Abstract Retroperitoneal abscess after duodenal ulcer perforation is a rare condition. A 71-year-old woman was admitted with 1 month of appetite loss and back pain. Abdominal computed tomography scan showed a retroperitoneal mass behind the third and fourth portions of the duodenum. Single-balloon enteroscopy revealed erosion of the third portion of the duodenum with leakage of contrast agent into the retroperitoneal space. Based on a preoperative diagnosis of retroperitoneal abscess after duodenal perforation, laparotomy was performed. Partial duodenectomy with a duodeno-jejunal anastomosis was performed, and her postoperative course was uneventful. Pathology showed an ulcer with no specific findings. KeyWords Duodenal ulcer Perforation Retroperitoneal abscess
Introduction Perforation of the duodenal bulb due to ulcer disease is common. However, perforation in other portions of the duodenum is rarely due to ulcer disease. If this does occur, the perforation may track toward the retroperitoneal space. We report a case of ulcer perforation in the third portion of the duodenum resulting in a retroperitoneal abscess.
A. Sadatomo (&) K. Koinuma T. Zuiki A. T. Lefor Y. Yasuda Department of Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498, Japan e-mail: [email protected]
Case report A 71-year-old woman visited her local physician with complaints of appetite loss and back pain for 1 month. She didn’t have any history of taking medicine, smoking and alcohol. Abdominal computed tomography (CT) scan revealed a mass near the pancreas. She was referred for further diagnosis and treatment. On admission, her blood pressure was 114/69 mmHg, pulse 82 per minute, and temperature 37.5 °C. Physical examination revealed left upper quadrant tenderness, but no guarding. Blood tests revealed a white blood cell count of 10,900/mm3, platelet count 398,000/mm3, and C-reactive protein of 23.36 mg/dl (Table 1). Abdominal CT scan showed a large mass located behind the third portion of the duodenum with lateral extension to the ligament of Treitz. No free air was seen in the peritoneal or retroperitoneal spaces (Fig. 1). A small amount of ascites was noted in the pelvic cavity. Based on these findings, a retroperitoneal tumor was suspected. Single-balloon enteroscopy was then performed, which showed an ulcerous lesion in the third portion of the duodenum. The ulcer bed was covered with necrotic tissue (Fig. 2). Contrast material leaking from the third portion into the retroperitoneal space was noted (Fig. 2). Biopsy specimen taken from the ulcer lesion was erosive mucosa. These findings were consistent with perforation of the third portion of the duodenum resulting in a retroperitoneal abscess. She was referred to the Department of Surgery, and emergent laparotomy performed. A mass, 15 cm in diameter, behind the third portion of the duodenum was found. The mass was hard with a thickened wall containing purulent material. A 2 cm perforation was identified in the posterior wall of the third portion of duodenum (Fig. 3). Due to marked inflammation of the duodenal wall and
123
374
Clin J Gastroenterol (2013) 6:373–377
Table 1 Laboratory data on admission 3
3
WBC
10.9 9 10 /mm
RBC
398 9 104/mm3
CRP
23.36 mg/dl
TP
6.5 g/gl
Hb
9.6 g/dl
Alb
2.7 g/gl
Ht
29.4 %
BUN
14 mg/dl
Plt
39.3 9 104/ll
Cr
0.42 mg/dl
PT-%
79.1 %
AST
86 mU/ml
PT-INR
1.12
ALT
40 mU/ml 264 mU/ml
H.pylori IgG Ab
(-)
LDH
CEA
2.7 ng/ml
Na
135 mmol/l
CA19-9
26 U/ml
K
3.5 mmol/l
Cl
96 mmol/l
surrounding tissues, closure of the perforation was not performed. Duodenectomy of both the third and fourth portions, including the proximal jejunum was performed and reconstructed with a duodeno-jejunostomy. A tube gastrostomy was placed intraoperatively, and a drain was placed into the abscess cavity. The bacteriological culture test on the pus was negative. Her postoperative course was uneventful except for poor gastric emptying, and she was discharged on the 39th postoperative day. Pathological examination of the resected specimen revealed that the cause of the perforation was a simple duodenal ulcer (Figs. 4, 5a, b).
Discussion The etiologies of retroperitoneal abscesses are varied and include perforation of the colo-rectum, infection of the
Fig. 1 CT scan showed an abscess cavity (arrow). No free air was seen in the peritoneal or retroperitoneal spaces
123
urinary tract, pancreatitis, appendicitis and postoperative complications, among others. A retroperitoneal abscess due to perforation of the duodenum is rare. Altemeier surveyed retroperitoneal abscesses treated between 1912 and 1961 at the Cincinnati General Hospital. Of 189 patients with an abscess, only two (0.95 %) originated in a duodenal perforation [1]. The most common reported cause of a duodenal perforation is a diverticulum. Other causes of intestinal ulcer are H. pylori infection, cytomegalovirus infection, tuberculosis infection, Crohn’s disease, drug-induced enteritis, radiation enteritis and foreign body such as a biliary stent, a nasojejunal feeding tube and a fish bone. In our case, there was no evidence of these diseases. A literature search including papers published from 1966 to 2012, showed only 11 cases of retroperitoneal abscess due to duodenal ulcer perforation [2–8] (Table 2). The sites of perforation in the duodenum included: duodenal bulb in two (18 %), the second portion in two (18 %), the third portion in one (9 %), and unknown in six (55 %). The most common symptom in patients with retroperitoneal perforation of the duodenum is epigastric and right upper quadrant pain. Other symptoms include nausea, vomiting and fever. Sign of peritonitis are rare in this condition. In the present case, the patient’s symptoms were appetite loss and back pain lasting for 1 month, which had not been getting worse. The clinical presentation varies greatly and requires a high index of suspicion. Radiologic imaging has been regarded as a useful tool to establish the diagnosis of a retroperitoneal abscess. In most patients (7/11, 64 %), there was a normal gas pattern on
Clin J Gastroenterol (2013) 6:373–377
375
Fig. 2 Single-balloon enteroscopy showed an ulcerous lesion covered with necrotic tissue in the third portion of the duodenum (White arrow). Contrast material leaked from the third portion into the retroperitoneal space (Black arrow)
Fig. 3 An intraoperative photograph showed a large perforation in the posterior wall of the third portion of the duodenum (arrow)
abdominal X-ray. However, CT scan can detect small amounts of gas and/or fluid in the retroperitoneal space. CT scan offers a standard for establishing the diagnosis of retroperitoneal abscesses and determining their anatomic extent [9]. However, in the cases reported, an accurate preoperative diagnosis was made in only three patients (3/ 11, 27 %).
Fig. 4 Resected specimen: excised duodenum was divided into two parts. Perforation sight was detected in the third portion of the duodenum (arrow)
Enteroscopy involves use of a video enteroscope for direct visualization of the small bowel. This procedure allows identification of intra-luminal abnormalities, such as tumor, ulcer, diverticulum and foreign body [9]. Leakage of contrast agent on X-ray during enteroscopy is evidence of an intestinal perforation. Both in the present patient and Patient #7 (Table 2), the radiographic contrast study supported a firm preoperative diagnosis of duodenal
123
376
Clin J Gastroenterol (2013) 6:373–377
Fig. 5 A high power view of the perforation site (arrow) showed necrotic tissue with inflammation cells infiltration. There was neither foreign body nor tumor. a (HE staining 910), b HE staining 920
perforation. To limit the extent of surgical intervention, an accurate preoperative diagnosis is very important. Among previously reported patients who died (Patients 2–7, Table 2), death was due to sepsis, pneumonia, and pulmonary embolism. However, the mortality rate has decreased, with the use of appropriate surgical drainage, improvements in perioperative care and the development of broad-spectrum antibiotics [10]. Surgical treatment was performed in all patients reported. The optimal surgical procedure varies, and depends on both the patients’ general condition and operative findings. Direct closure of the perforation site with omentopexy and drainage may be possible when intra-abdominal inflammation is mild and the perforation is small. When inflammation is severe or the site of perforation is not small, digestive tract diversion such as pyloric exclusion with a Billroth-II reconstruction or tube gastrostomy should be used to minimize the risk of leakage at the site of perforation. In the present patient, inflammation of the third and fourth portions of the duodenum was severe, but the second portion was not inflamed, allowing safe conduct of an anastomosis between the second portion and the jejunum. To allow adequate decompression of the anastomotic site in the postoperative period, a gastrostomy was placed. A perforated ulcer in the third portion of the duodenum with formation of a retroperitoneal abscess is a rare entity, and is occasionally difficult to diagnose. Enteroscopy is a helpful tool to establish the diagnosis. Optimal surgical therapy should be performed based on the individual patients’ condition and operative findings.
Table 2 Cases of retroperitoneal abscess from duodenal ulcer perforation Patient No
Author
Years
Age
Sex
Complaints
Chest X-ray findings
Preoperative diagnosis
Site of perforation
Treatment
Outcome
1
Britt
1966
62
M
Epigastric pain
Non-specific
Perforation of appendix
Drainage, duodenostomy
Alive
2
Hashmonai
1971
58
F
F
4
48
M
Drainage, transverse loop colostomy Drainage, appendectomy Drainage
Died
64
Distended loops of colon, ileus of bowel –
Perforation of colon
3
5
75
M
Fever, apptite loss Abdominal patin Abdominal patin, vomit –
Posterior wall of bulb Unknown (autopsy)
Drainage, Closure of the perforation
Died
123
Non-specific
Non-specific
Perforation of appendix Duodenal ulcer
Unknown (autopsy) Unknown (autopsy)
Strangulated right inguinal hernia
Third portion
Died Died
Clin J Gastroenterol (2013) 6:373–377
377
Table 2 continued Patient No
Author
Years
Age
Sex
Complaints
Chest X-ray findings
Preoperative diagnosis
Site of perforation
Treatment
Outcome
6
Edmondson
1972
54
M
Abdominal pain, vomit
Density in the right abdomen
Posterior wall
Drainage, Duodenogastric resection, Billroth II reconstruction
Died
7
Catalano D
1984
58
M
Abdominal pain, fever
Nonspecific
Unknown
Drainage, Duodenogastric resection
Died
8
Sturup J
1985
51
F
Abdominal pain
–
Perforation of duodenal or appendix Duodenal ulcer perforation Peritonitis
Posterior wall
Alive
9
Vellar ID
1989
55
F
Abdominal pain
Nonspecific
Pancreatic abscess
10
Wong
2004
40
–
No peritonism
Nonspecific
Perforated viscus
Drainage, Closure of the perforation, gastrojejunal anastomosis Drainage, Closure of the perforation, gastrojejunal anastomosis, jejunostomy, T-tube drainage Drainage
11
55
–
No peritonitis
Nonspecific
Perforated viscus
Present case
71
F
Appatite loss, back pain
Nonspecific
Perforation of duodenal
Disclosures Conflict of Interest: The authors declare that they have no conflict of interest. Human/Animal Rights: All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008(5). Informed Consent: Informed consent was obtained from all patients for being included in the study.
References 1. Altemeier WA, Alexander JW, et al. Retreoperitoneal abscess. Arch Surg. 1961;83:512–24. 2. Britt LG, Wolf RY. Postbulbar ulcer with retrocecal abscess. A case report. Arch Surg. 1966;92(1):98–100. 3. Hashmonal M, Abrahamson J, Erlik D, Schramek A. Retroperitoneal perforation of duodenal ulcers with abscess formation.
4.
5.
6. 7.
8.
9.
10.
Posterior wall of the second portion Posterior wall of bulb Posterior wall of the second portion Posterior wall of the third portion
Drainage, Closure of the perforation, pyloric exclusion, gastrojejunal anastomosis, jejunostomy, Drainage, duodenectomy, duodenojejunostomy
Alive
Alive
Alive
Alive
Report of four cases and survey of the literature. Ann Surg. 1971;173(3):409–14. Edmondson HT, Terry DB Jr. Retroperitoneal abscess from posterior perforation of duodenal ulcer. J Med Assoc Ga. 1972;61(11):374–5. Catalano D, Troianiello B. Left side abdominal abscess from a retroperitoneal perforation of a duodenal ulcer. Rofo. 1984; 141(1):111–3. Sturup J, Raahave D. Retroperitoneal perforation of duodenal ulcer. Ann Chir Gynaecol. 1985;74(6):299–300. Vellar ID, Vellar D. Retroperitoneal perforation of a peptic ulcer situated in the second part of the duodenum. Aust N Z J Surg. 1989;59(7):592–3. Wong CH, Chow PK, Ong HS, Chan WH, Khin LW, Soo KC. Posterior perforation of peptic ulcers: presentation and outcome of an uncommon surgical emergency. Surgery. 2004;135(3):321–5. Dyr CE, Graffiney RR, Dykes TM, Moyer MT. Endoscopic and radiographic evaluation of the small bowel in 2012. Am J Med. 2012; 125(12):1228.e1–e12. Tunguntla A, Raza R, Hudgins L. Diagnostic and therapeutic difficulties in retroperitoneal abscess. South Med J. 2004;97(11): 1107–9.
123
