What is Duodenal Perforation?
The duodenum is a part of the digestion system, situated between the stomach and the small intestine. It’s divided into four sections:
1. The first segment, known as the duodenal bulb, connects to the liver through a tissue called the hepatoduodenal ligament, which holds the hepatic artery, the portal vein, and the common bile duct.
2. The second segment wraps around the head of the pancreas.
3. The third segment is the horizontal part, with the superior mesenteric vessels lying in front of it.
4. The fourth segment follows the jejunum, which is part of the small intestine.
Damage to the duodenum, or a “duodenal perforation,” is a rare but potentially deadly condition. Death rates for this condition vary, with some studies noting rates from 8% to 25%. It was first described in 1688, but it wasn’t until 1894 that the first successful surgical closure of a perforated duodenal ulcer was reported. Over the years, different techniques for repairing these perforations have been developed.
A duodenal perforation happens when a hole forms in this part of the intestine. If the hole is “free,” the contents of the bowel can leak into the abdomen, leading to widespread inflammation. If the hole is “contained,” surrounding organs, like the pancreas, can wall off the area and prevent leakage. Frequently, duodenal perforations are caused by peptic ulcer disease, typically associated with night-time abdominal pain or a sensation of hunger.
If a perforation happens, it generally causes sudden, severe pain in the upper abdomen. But in elderly patients, or those with weakened immune systems, signs might be difficult to detect and could delay diagnosis. Imaging plays a crucial role in identifying the issue, which can allow for early medical response. Choosing the right treatment option and accurately assessing the risks can help lower the chances of further health issues or death.
What Causes Duodenal Perforation?
The duodenum, part of the digestive system, can experience various problems. One significant issue is Peptic Ulcer Disease (PUD), often caused by an H. pylori infection or non-steroidal anti-inflammatory drugs (NSAIDs). Although fewer people have been getting PUD recently, it’s still a primary reason for a hole, or perforation, to form in the duodenum. People who smoke, have had PUD before, are under severe stress, or take corticosteroids are more likely to get a perforated peptic ulcer. Drinking alcohol may damage the stomach lining and increase gastrin secretion but doesn’t necessarily cause PUD.
Other possible problems for the duodenum include the occurrence of diverticula, which are bulging pouches that can form in the lining of the gastrointestinal tract. Infections from diseases like tuberculosis, rotavirus, or norovirus and parasitic infections from worms such as Ascaris lumbricoides can also harm the duodenum. People who have autoimmune conditions like scleroderma, Crohn’s disease, or abdominal polyarteritis nodosa can also experience issues.
Other causes of duodenal problems include duodenal ischemia (restricted blood flow), gallstones stuck in the duodenum, chemotherapy, and tumors. Also, medical procedures such as endoscopies or surgeries can cause damage. During these procedures, there’s a risk of perforating the duodenum, especially in treatments involving surgical instruments.
Injuries affecting only the duodenum are not common and usually happen alongside damage to other organs. Sharp and thin foreign objects also pose a risk of causing a perforation. In some cases, newborn babies can have spontaneous perforations, having a hole in the duodenum without an identifiable cause.
Risk Factors and Frequency for Duodenal Perforation
Peptic ulcer disease (PUD), which affects 4 million people worldwide each year, is a leading cause of holes or perforations in the small intestine, specifically in an area called the duodenum. While the occurrence of PUD has decreased lately due to treatments for a type of bacteria called Helicobacter pylori and the use of certain stomach acid-controlling medications, duodenal perforations linked to PUD remain a concern.
- Each year, between 1.5% to 3% of people develop PUD.
- About 5% of individuals with PUD will experience a perforation in their lifetime.
- The rates of perforations are possibly high due to an aging population, and overuse of non-steroidal anti-inflammatory drugs (NSAIDs), which can interact with certain depression medications and steroids.
- 50% to 80% of those with perforated duodenal ulcers also have the H. pylori bacterium.
- Ulcer perforations tend to occur more frequently in the morning due to changes in acid secretion throughout the day.
In addition, following a certain procedure (ERCP), where a flexible tube is used to examine the pancreatic and bile ducts, duodenal perforations can occur. Factors that increase the risk of this include a dysfunction in a particular muscle (Sphincter of Oddi), older age, pre-existing cuts, unusual anatomy, and the injection of a contrast medium (a type of dye).
- The rate of duodenal perforations after ERCP procedures ranges from 0.09% to 1.67%.
Finally, it’s not common, but abdominal injuries and swallowed foreign objects can also cause these types of perforations.
- Less than 2% of traumatic abdominal injuries involve the duodenum.
- Less than 1% of swallowed foreign objects result in gastrointestinal perforations.
Signs and Symptoms of Duodenal Perforation
If you’re experiencing symptoms of a perforated peptic ulcer (PPU), it’s important to get checked by a healthcare professional as soon as possible. The main symptoms include ongoing abdominal pain and rapid heartbeat. The pain usually starts suddenly and might not go away even if you try over-the-counter remedies. There might also be a feeling of stiffness or rigidity in the abdomen.
Healthcare providers often look for specific signs to diagnose PPU. These signs are usually seen in different phases after the onset of symptoms:
- Initial phase (within two hours): Rapid heartbeat, pain in the upper abdomen, and cold extremities
- Second phase (two to twelve hours): Pain spreading throughout the abdomen and worsening with movement; tenderness and stiffness in the lower right abdomen
- Third phase (more than twelve hours): Abdominal swelling, fever, and low blood pressure
However, patients with a retroperitoneal perforation might present slightly different symptoms, often appearing more gradually and without signs of an inflamed abdominal membrane.
Testing for Duodenal Perforation
Several laboratory tests are typically done if a perforated peptic ulcer (PPU) is suspected. These include the following:
- Measuring the level of serum amylase in the blood. If it’s less than four times the normal level, this could be a sign of a PPU.
- Examining serum gastrin levels – particularly useful for those who have had recurrent ulcers, and it helps establish the diagnosis of Zollinger-Ellison syndrome, an ailment that leads to peptic ulcers.
- Checking for leukocytosis and a high C-reactive protein level, which could indicate inflammation or infection.
- Taking blood cultures before antibiotics are given.
- An arterial blood gas test, which gauges the extent of metabolic compromise in those with a serious condition like sepsis.
Imaging can also provide important clues. An urgent upright chest radiograph (CXR) is a basic test for duodenal perforation if a person has sharp upper abdominal pain. This radiograph can detect free air below the diaphragm in about 75% of patients. However, it may not show anything unusual, especially if it’s done shortly after symptoms have started. A normal CXR doesn’t mean a duodenal perforation can be ruled out. In such cases, where there is clinical suspicion even though the patient is stable, further evaluation with a computed tomography (CT) scan is advised.
A non-contrast CT scan is good for spotting free air just under the front abdominal wall in people with acute kidney injury. The detection rate of PPU by CT scan is impressively accurate, at around 98%. A double-contrast CT scan is an excellent method for diagnosing a perforated duodenum. The CT scan can show several features of a perforation, including thickening of the duodenal wall, spleen enlargement, escape of the oral contrast dye from the stomach, the presence of air outside the digestive tract, fat stranding (an abnormality found in soft tissues), and fluid collection around the duodenum.
Treatment Options for Duodenal Perforation
Duodenal perforations, or holes in the first part of the small intestine, are classified into two main types: contained and non-contained perforations. Each type requires different management approaches.
Contained perforations are those where the surrounding organs, such as the pancreas, prevent any intestinal content from spilling out. In these situations, a less invasive, conservative approach is often used. This involves confirming that there’s no leakage, then treating the patient with strategies such as fluids given intravenously, a temporary halt on eating and drinking, medications to reduce stomach acid and treat infection, and close monitoring. This method is often referred to as the “R”s: repeating clinical examinations, evaluating lab data, providing necessary resources and life-supporting measures, and always being ready to perform surgery if needed.
On the other hand, non-contained perforations are those where the contents of the intestine leak into the abdominal cavity. This type is further split into minor and major perforations, each requiring different treatment approaches.
For minor non-contained perforations, endoscopic techniques or simple surgical procedures can be employed. Endoscopic repair involves use of special devices that can close up the perforation from the inside. In surgeries, the hole can be closed up by using a piece of tissue from the thin layer of fat in the abdomen known as the omentum. There’s no clear benefit to placing a drain after these surgeries.
Major non-contained perforations often need more complex surgeries to repair the damage. The type of operation depends on which part of the intestine the perforation is located in. Options include creating a new connection between different parts of the digestive system to bypass the damaged area.
What else can Duodenal Perforation be?
Before any detailed medical scans, a doctor must consider a number of potential causes for upper stomach pain. These can include:
- Abdominal aortic aneurysm (a bulging in the main blood vessel in your body)
- Acute coronary syndrome (sudden reduced blood flow to the heart)
- Aortic dissection (a tear in the wall of the main artery in your body)
- Pancreatitis (inflammation of the pancreas)
- Appendicitis (inflammation of the appendix)
- Boerhaave syndrome (tearing of the esophagus, the tube that connects your mouth to your stomach)
- Cholecystitis (inflammation of the gallbladder)
- Cholelithiasis (gallstones)
- Diverticulitis (inflammation of pouches in the colon)
- Duodenitis (inflammation of the first part of the small intestine)
- Esophagitis (inflammation of the esophagus)
- Gastroesophageal reflux disease (GERD, a chronic disease that occurs when stomach acid flows back into the esophagus)
- Foreign body ingestion (swallowing an object)
- Gastritis (inflammation of the stomach lining)
- Hepatitis (inflammation of the liver)
- Ventral hernia (a bulge of tissues through an opening of weakness within your abdominal wall muscles)
- Mesenteric ischemia (poor blood supply to the intestines)
- Small bowel obstruction (blockage in the small intestine)
- Volvulus (twisting of the stomach or intestines)
- Pneumonia (infection that inflames the air sacs in one or both lungs)
Physicians need to consider these possibilities and perform relevant tests to make an accurate diagnosis.
What to expect with Duodenal Perforation
The mortality rate for patients with a perforated peptic ulcer (PPU) can range from 1.3% to 20%, with some studies suggesting a 30-day mortality rate of 20%. A key factor influencing the patient’s prognosis is the time between the occurrence of the perforation and when treatment is received. If the treatment is delayed by more than 24 hours, it tends to increase the mortality rate.
There are two main scoring systems used to predict the outcomes in the case of a duodenal perforation: the American Society of Anesthesiologists (ASA) score and the Boey score. The Boey score considers factors such as serious concurrent illness, preoperative shock, and the duration of the perforation over 24 hours. If all these factors are positive, this leads to a total score of 3, which predicts a mortality risk of 38% and a morbidity risk of 77%.
The American Society of Anesthesiologists (ASA) score, on the other hand, considers the existence of any systematic disease and the degree of co-morbidity to anticipate the outcome of PPU. Notably, the mortality rate could increase with the following risk factors: existing health conditions, surgery involving the removal of part of the stomach, shock upon admission, female gender, elderly patients, metabolic acidosis, delay in presentation of more than 24 hours, acute kidney failure, low levels of albumin in blood, smoking, being underweight, and being older than 65.
The postoperative mortality rate for PPU patients is estimated to be 6% to 10%. Factors such as treatment delays of more than 24 hours, age over 60, existing illnesses, and low systolic blood pressure also contribute to increasing the mortality rate.
Possible Complications When Diagnosed with Duodenal Perforation
Sepsis is a frequent occurrence and contributes to approximately 40-50% of deaths in patients suffering from PPU (perforated peptic ulcer). When these patients arrive for surgery, about a third of them have sepsis. Beyond that, over 25% of such patients can develop a condition known as “septic shock” within the first month following surgery, which results in a mortality rate of 50-60%. After surgery, about 30% of patients experience complications.
Several risk factors that may increase postoperative complications include being older than 40, having experienced shock before, and having a larger perforation size. Typical surgical complications may include pneumonia, wound rupture, infection in the abdominopelvic cavity, hernia due to surgery, a connection between the skin and intestine, abscess or collection within the abdomen, infection of the surgical site, and ileus (a disruption of the normal propulsive ability of the gastrointestinal tract). It has been noted that the most common post-surgery complication is infection at the site of surgery, occurring in 32% of cases.
Common complications include:
- Pneumonia
- Wound rupture (wound dehiscence)
- Infection in the abdominopelvic cavity (peritonitis)
- Hernia due to surgery (incisional hernia)
- Connection between the skin and intestine (enterocutaneous fistula)
- Abscess or collection within the abdomen (intra-abdominal collection/abscess)
- Infection of the surgical site
- Disruption of the normal propulsive ability of the gastrointestinal tract (Ileus)
Recovery from Duodenal Perforation
An observational study found that a specific care plan from when patients are admitted to 3 days after a laparoscopic repair surgery decreased the death rate within 30 days from 27% to 17%. This care plan included reducing delays in surgery and taking measures to prevent, detect, and treat sepsis.
Small clinical trials in Turkey indicated that in patients with low-risk health scores, removing tubes early and starting oral intake sooner shortened their hospital stay by about three days.
A thorough review by Wong and colleagues showed that for patients with perforated duodenal ulcers, getting rid of H. pylori bacteria significantly reduced the recurrence of ulcers at eight weeks and one year after surgery.
Follow-up endoscopy is typically not recommended for patients with perforated duodenal ulcers due to the low risk of these ulcers turning cancerous.
Preventing Duodenal Perforation
It’s important for patients to be mindful of certain risk factors that could potentially lead to a medical condition known as duodenal perforation. This condition is most frequently caused by peptic ulcers. Therefore, preventing duodenal perforation involves the same steps as preventing peptic ulcer disease.
Patients should try to refrain from using medications known as NSAIDs. If a patient does need to take NSAIDs for any reason, they should try to use the smallest possible dose, and only for a short period of time. If a patient needs to take NSAIDs for a longer period, they might consider protective measures like taking PPI or H2 blockers.
People who have been diagnosed with peptic ulcer disease should always follow the advice of their gastroenterologist. Additionally, quitting smoking can greatly reduce the risk of developing these conditions.