A Novel Approach to Managing Giant Duodenal Ulcer Perforations: Minimizing Ostomies, Maximizing Decompression. A Case Report

Background: Peptic ulcer perforation is a deadly complication of duodenal ulcers. The literature is still sparse in terms of giant duodenal perforations. There exist a variety of techniques to decompress the duodenum after repair which leave the patient with multiple ostomies that require extensive postoperative care. Case presentation: In this case we present a patient with AIDS who was found to have a large duodenal ulcer perforation. Intraoperatively the fragility of the patient’s duodenum warranted a method of decompression that would keep the integrity of the duodenal tissue. The common method of lateral duodenostomy was not the best option and instead a gastro-jejunal feeding tube was altered into a gastro-duodenal tube to avoid creating another ostomy. Postoperatively she did not show signs of leak, but eventually died from sepsis secondary to fulminant AIDS. Conclusions: We propose this technique as a novel method of decompressing the duodenum. This new method eliminates the need for excessive ostomies and has the possibility to make the postoperative transition simpler.

Complicated giant duodenal ulcer in the HIV-infected patient

This article presented the clinical observation of the giant duodenal ulcer complicated by bleeding in the HIV-infected patient. The original method of forming the duodenal stump was used during the resection of the stomach by Billroth-2. The method was characterized by using the post-ulcer stenotic ring as a skeleton of the formed duodenal stump and the double-row continuous suture that allowed to avoid the suture insufficiency in the patient.

Rare case of a giant duodenal ulcer penetrating the pancreas during antiangiogenic treatment

We report a case of a patient with renal cell carcinoma on pazopanib, who presented with severe upper gastrointestinal bleeding. Endoscopy showed a giant bulbar ulcer with a visible vessel of 4 mm. Due to unavailability of surgical rescue backup, large calibre vessel treatment was delayed. Endoscopy was repeated after 48 hours and showed a reduction in the vessel diameter. Endoscopic adrenalin injection and electrocoagulation were performed. However, the vessel increased in size and became pulsatile. The patient was operated, confirming a giant bulbar ulcer penetrating the pancreas with active bleeding from the gastroduodenal artery. Pazopanib therapy was suspended, and the patient is asymptomatic. Antiangiogenic treatment has been associated with gastrointestinal bleeding, perforation and fistulisation. Although we cannot confirm the causal association between the penetrating ulcer and pazopanib, the absence of Helicobacter pylori infection or non-steroidal anti-inflammatory drugs, and the reported cases of gastrointestinal bleeding during these therapies favour a possible association.