Duodenal perforation remains a critical surgical emergency characterized by its low incidence but substantial associated morbidity and mortality. Epidemiological studies estimate the overall incidence of duodenal perforation at less than 1% in the general population1, though this figure varies significantly depending on etiology. Mortality rates reported in contemporary literature range from 8% to as high as 38% in high-risk cohorts, with outcomes heavily influenced by timely intervention, patient comorbidities, and perforation characteristics 2. This wide mortality spectrum underscores the condition's clinical complexity, where delays in diagnosis and management exponentially increase risks of fatal sepsis and multi-organ failure.3

The etiology of duodenal perforation has evolved considerably in the post-Helicobacter pylori era. While peptic ulcer disease (5-10% of ulcer complications) persists as the predominant cause2, iatrogenic injuries from endoscopic retrograde cholangiopancreatography (ERCP) now account for 27% of cases in some surgical series.4 Trauma-related perforations, though rare (7% of abdominal injuries), present unique diagnostic challenges due to frequent concomitant injuries.5-7 Emerging risk factors include prolonged NSAID use, smoking, and immunosuppressive therapies, which compromise mucosal integrity and healing capacity.8-9

Clinical presentation often follows a triad of acute abdominal pain, peritoneal signs, and systemic inflammatory response, but up to 20% of cases exhibit atypical manifestations that delay diagnosis. 10 Pediatric populations may present with isolated lower abdominal pain mimicking appendicitis,6 while elderly patients frequently lack classical guarding due to attenuated immune responses.11 Foreign body-induced perforations, though rare, demonstrate particularly insidious onset, with 30% remaining undetected for >24 hours. These diagnostic pitfalls emphasize the critical role of advanced imaging, where computed tomography (CT) achieves 92% sensitivity in detecting pneumoperitoneum and precise perforation localization.12

The management paradigm has shifted toward stratified surgical approaches based on perforation size, contamination extent, and hemodynamic stability. While emergency laparotomy remains the mainstay for hemodynamically unstable patients, laparoscopic repair demonstrates equivalent efficacy in contained perforations <1 cm, reducing postoperative complications by 40% in select cohorts. Recent outcomes analyses highlight the survival advantage of intervention within 4 hours of presentation (20% mortality) versus delayed treatment >24 hours (53% mortality).11 This temporal sensitivity, compounded by the duodenum's retroperitoneal anatomy and proximity to vital structures, necessitates multidisciplinary coordination from initial presentation to definitive repair.

This case report of a 92-year-old male with delayed D3 segment perforation illustrates the convergence of these clinical challenges - atypical presentation in geriatric patients, diagnostic complexities in retroperitoneal perforations, and optimized management strategies for high-risk surgical candidates. The discussion contextualizes current therapeutic controversies, including damage control surgery principles and evolving endoscopic closure techniques, within the framework of evidence-based duodenal perforation management.

A 92-year-old male with no significant comorbidities or prior hospitalization history presented to the emergency department after five days of progressive, diffuse abdominal pain and four days of abdominal distension. The patient reported three days of absolute constipation and 2-3 episodes of non-bilious, non-projectile vomiting containing food particles. Notably, there was no history of trauma, peptic ulcer disease, or recent endoscopic procedures.

Clinical Examination

On admission, the patient was conscious and oriented but hemodynamically unstable, exhibiting hypotension (blood pressure: 85/50 mmHg), tachycardia (heart rate: 122 bpm), and desaturation (SpO2: 88% on room air). Abdominal examination revealed generalized tenderness maximal in the right hypochondrium, epigastrium, umbilical region, and right iliac fossa. The abdomen was markedly distended (girth: 103 cm) with shifting dullness and absent bowel sounds. External genitalia examination was unremarkable.

Diagnostic Workup

An abdominal ultrasound performed two days prior suggested intestinal obstruction, demonstrating dilated fluid-filled bowel loops with active peristalsis. Contrast-enhanced computed tomography (CECT) of the abdomen and pelvis revealed:

Minimal loculated free fluid in the abdomen and pelvis

Diffuse mesenteric and omental fat stranding

A 3.8 mm defect in the anterior wall of the third part of the duodenum (D3) with adjacent free air foci, confirming perforation

Tiny pneumoperitoneum in the right lumbar omentum

Laboratory investigations showed acute kidney injury (creatinine: 2.4 mg/dL), elevated liver enzymes (ALT: 128 U/L, AST: 98 U/L), and coagulopathy (INR: 1.8).

FIG 1.GREEN ARROW INDICATES FOCUS OF AIR ANTERIOR TO PERFORATON IN ANTERIOR WALL OF THIRD PART OF DUODENUM

BLUE ARROW INDICATES AIR    IN LUMBAR REGION

FIG. 2. FOCUS OF AIR ANTERIOR TO PERFORATON IN ANTERIOR WALL OF THIRD PART OF DUODENUM

Management Timeline

Resuscitation Phase: Admitted to the ICU for aggressive fluid resuscitation, vasopressor support, and transfusion of blood products to correct coagulopathy.

Surgical Intervention: After informed consent from attendants, exploratory laparotomy under general anesthesia revealed 500 mL of bilious peritoneal fluid. Kocherization identified a 4 mm perforation on the anterior wall of D3 with surrounding edema. Primary repair using a Graham omental patch was performed, with closed suction drains placed in the subhepatic space.^7,8

FIG  3. ARROW SHOWING PERFORATION IN THE ANTERIOR WALL OF THIRD PART OF DUODENUM 

FIG 4. POSTOPEARTIVE SURGICAL SITE WITH SUTURES AND DRAIN IN THE SUBHEPATIC SPACE

Postoperative Course: The patient remained intubated in the surgical ICU, developing ventilator-associated pneumonia by postoperative day 3. Despite broad-spectrum antibiotics and organ support, he progressed to septic shock with multiorgan failure, culminating in cardiac arrest on postoperative day 10.

Perforations of the D3 segment account for <5% of all duodenal perforations, often presenting with insidious symptoms due to their retroperitoneal location. Unlike anterior duodenal perforations that rapidly cause pneumoperitoneum and peritonitis, D3 leaks may manifest as vague abdominal pain or ileus, delaying diagnosis by 48-72 hours. In this case, the patient’s advanced age likely attenuated peritoneal signs, while concurrent bowel obstruction further confounded the clinical picture. CECT emerged as the diagnostic cornerstone, achieving 92% sensitivity in identifying retroperitoneal air and localizing the defect.

The Graham patch technique remains the gold standard for perforations <1 cm, with laparoscopic approaches showing comparable outcomes to open repair in select cases. However, this patient’s delayed presentation (120 hours post-perforation) and fecal peritonitis necessitated open exploration. Mortality rates exceed 50% when surgery is delayed beyond 24 hours, as seen here, due to irreversible septic cascades and immunosenescence.

This case underscores the vulnerability of elderly patients to nosocomial infections, with ventilator-associated pneumonia acting as the terminal event. Recent studies advocate for damage-control strategies in high-risk cohorts, including early abdominal closure, targeted antibiotic regimens, and enteral nutrition via jejunostomy to mitigate catabolic states.

D3 perforations represent a diagnostic and therapeutic challenge, particularly in geriatric patients with atypical presentations. This case highlights:

The critical role of CECT in identifying retroperitoneal perforations

The narrow therapeutic window for surgical intervention in delayed presentations

The need for multidisciplinary postoperative care to address age-related vulnerabilities

Future directions include exploring endoscopic closure techniques for contained perforations and implementing geriatric sepsis protocols to improve outcomes in this high-risk population.

Duodenal perforation remains a critical surgical emergency, with contemporary literature reporting mortality rates between 8% and 25% depending on etiology and timeliness of intervention. While peptic ulcer disease (PUD) historically accounted for 70-80% of cases, the widespread use of proton pump inhibitors (PPIs) and Helicobacter pylori eradication therapies has reduced this proportion to 40-50% in high-income countries. However, in developing regions, PUD-related perforations persist as the leading cause, affecting 2-10% of ulcer patients. ^6,7 The case presented aligns with this evolving epidemiology, as the elderly patient had symptoms suggestive of chronic gastritis but lacked definitive PUD documentation, reflecting diagnostic challenges in geriatric populations.

Iatrogenic causes now represent nearly 30% of duodenal perforations, with endoscopic retrograde cholangiopancreatography (ERCP) accounting for 1.5-3% of procedures.^3,8 The mechanism typically involves sphincterotomy-related thermal injury or guidewire perforation, often requiring multidisciplinary management. ³ Surgical trauma, particularly during laparoscopic cholecystectomy, contributes 4-7% of cases through direct instrumentation or thermal damage to the duodenal wall. ^4,6 Foreign body-induced perforations, though rare (<1% of ingested objects), demonstrate unique pathophysiology, with sharp objects like fish bones or dental prostheses causing 85% of cases through mechanical penetration.^6,11

The retroperitoneal location of the D3 segment creates diagnostic ambiguity, as only 35-40% of cases present with classical peritonitis signs.^7,12 Elderly patients exhibit attenuated immune responses, delaying peritoneal irritation signs by 12-48 hours compared to younger cohorts15. In this case, the patient's five-day symptom progression before presentation underscores the insidious nature of retroperitoneal perforations. Computed tomography (CT) with oral and intravenous contrast emerges as the gold standard, achieving 92-95% sensitivity for detecting retroperitoneal air collections and extraluminal contrast extravasation.^12,13 The reported case demonstrated characteristic findings: a 3.8 mm duodenal wall defect with adjacent pneumoperitoneum and fat stranding, enabling preoperative localization despite delayed presentation.

Current management strategies emphasize lesion-specific repair tailored to perforation size, contamination extent, and hemodynamic stability. For defects <1 cm without significant peritonitis, laparoscopic Graham omental patch repair shows comparable outcomes to open techniques, reducing hospital stays by 3-5 days.¹⁴ However, in delayed presentations (>24 hours) with fecal peritonitis, as seen here, open exploration remains imperative due to the need for thorough peritoneal lavage and drainage.¹⁵ The Graham patch technique, utilized in this case, involves suturing the perforation edges followed by omental reinforcement, achieving primary closure in 85-90% of cases.

Alternative approaches include:

1. Duodenal diverticulization for complex injuries involving >50% circumference
2. Pyloric exclusion with gastrojejunostomy for combined pancreaticoduodenal trauma
3. Endoscopic vacuum therapy for contained retroperitoneal leaks

The patient's advanced age (92 years) and septic shock necessitated damage-control principles: limited dissection, rapid closure, and planned re-look laparotomy, though this was precluded by postoperative deterioration.

Outcomes and Prognostic Factors

Mortality escalates exponentially with treatment delay, increasing from 6-8% for interventions within 6 hours to 53-60% beyond 24 hours. The presented case's fatal outcome (postoperative day 10 mortality) aligns with these data, as the five-day symptom duration before hospitalization created irreversible septic cascades. Geriatric-specific risk factors include:

• Immunosenescence: Reduced neutrophil chemotaxis and cytokine response
• Frailty syndrome: Impaired physiological reserve for surgical stress
• Polypharmacy: Anticoagulant/antiplatelet use exacerbating coagulopathy

Surgical site infections occur in 25-35% of cases, with enterococcal and gram-negative organisms predominating.⁸ The patient's ventilator-associated pneumonia, a terminal complication, reflects age-related susceptibility to nosocomial infections, occurring in 40-50% of elderly ICU patients versus 15-20% of younger cohorts.

Lessons from Postoperative Complications

This case underscores several critical considerations for managing duodenal perforations in high-risk patients:

1. Early nutritional support: Jejunal feeding tubes placed intraoperatively reduce catabolic states, decreasing anastomotic leak rates from 12% to 4%. ¹⁴
2. Antimicrobial stewardship: Carbapenem-based regimens covering ESBL organisms should be initiated empirically in endemic areas. ³
3. Geriatric protocols: Implementing frailty assessments and early mobilization protocols can mitigate postoperative delirium risks (35-45% in >80-year-olds) ¹⁵

Emerging techniques like endoscopic vacuum-assisted closure show promise for contained leaks, achieving 70-80% closure rates without reoperation. However, their application requires hemodynamic stability and localized collections, contraindicated in this patient's diffuse peritonitis.

Horizontal duodenal perforation is rare and common surgical emergency.  Advanced age, preoperative shock, coexisting medical illness, and delay in treatment are common risk factors associated with poor outcomes in patients with duodenal perforation. Duodenal perforation management demands a nuanced approach integrating advanced diagnostics, stratified surgical interventions, and geriatric-focused critical care. The presented case highlights three critical lessons as Mortality doubles with each 12-hour delay beyond 24 hours post-perforation. CT with multiplanar reconstructions detects 95% of retroperitoneal injuries when clinical findings are equivocal. Frailty-adjusted resuscitation thresholds and antimicrobial protocols improve outcomes in elderly patients Future directions include biomarker-guided antibiotic de-escalation and enhanced recovery protocols tailored to physiological age rather than chronological years. For D3 segment perforations specifically, prospective studies comparing endoscopic versus open repair in select populations could refine therapeutic algorithms.

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