Duodenal perforation

A 29-year-old woman with polycystic ovary syndrome had her first in vitro fertilization cycle of leuprorelin acetate, FSH, and human chorionic gonadotropin (hCG) (67). Within 2 days she complained of abdominal distension, shortness of breath, and abdominal pain. Over the next few days she developed massive ovarian enlargement, ascites, hyponatremia, respiratory failure, and renal insufficiency. This was further complicated by duodenal perforation, probably due to severe physical stress. 

Five cases of gastric perforation (rather than the more common duodenal perforation) have been reported in young male smokers of crack, all of whom had only brief histories of prodromal symptoms and none of whom had long-standing peptic ulcer disease (196). 

Perforation can occur elsewhere than in the colon in one case a duodenal ulcer was apparently made to perforate. In both this and another case of perforation of a sigmoid diverticulum the complication was not immediately recognized, the duodenal perforation only being detected 5 days after administration of the barium meal (SEDA-17, 535). 

An infant with persistent fetal circulation treated with tolazoline developed gastric ulceration and perforation (1). The first symptoms occurred 14 hours after the start of therapy, and there was free air in the abdomen 34 hours later. Duodenal perforation also occurred in a 31-hour-old infant with meconium aspiration treated with tolazoline for 6 hours the defect required surgical correction (2). 

ThumbeVK, Houghton AD, Smith MSH (2000) Duodenal perforation by a Wallstent. Endoscopy 32 495-497 Truong S, Bohndorf V, Gellert H (1 2) Self-expanding metal stents for palliation of malignant gastric outlet obstruction. Endoscopy 24 433-435... 

A duodenal perforation in a 6.5-year-old male child with thalassaemia major was reported [31 ]. He received 625 mg deferasirox daily since the age of 3, and was not on any other medication. After treatment, he resumed chelation therapy together with omeprazole to prevent peptic ulcer. One study indicated no link between lactose intolerance and the incidence of G1 adverse effects in beta-thalassaemia patients treated with deferasirox [32 ]. 

Iatrogenic duodenal injuries are rare complications of endoscopy. Perforation rarely occurs during routine endoscopy but may result from incorrect mucosal biopsy. Duodenal perforation is much more likely to follow endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy. The latter procedure involves a diathermy cut through the muscular sphincter of Oddi in a cranial direction. The line of the cut should ideally run in a twelve o clock direction to the papilla, and retroperitoneal perforation is much more likely to occur if there is significant deviation from this approach. The reported incidence is 0.5%-2% (Zissin et al. 2000). On CT,... 

Fig. 9.27. A duodenal perforation following a diagnostic endoscopic US. CT scan shows retroperitoneal air bubbles and extravasation of the orally ingested contrast medium...

Croce E, Golia M, Russo R et al (1999) Duodenal perforations after laparoscopic cholecystectomy. Surg Endosc 13 523-525... 

Hofer GA, Cohen A] (1989) CT signs of duodenal perforation secondary to blunt abdominal trauma. J Comput Assist... 

NSAIDs are one of the most widely used classes of medications in the United States, particularly in the elderly.4 More than 20,000 deaths occur in the United States per year as a direct result of adverse events related to NSAID use. Chronic NSAID ingestion leads to symptoms of nausea and dyspepsia in nearly half of patients. Peptic ulceration occurs in up to 30% of patients who use NSAIDs chronically, with gastrointestinal bleeding or perforation occurring in 1.5% of patients who develop an ulcer. NSAID-related peptic ulcers usually occur in the stomach duodenal ulcers are much less common. 

The most common bisphosphonate adverse effects are nausea, abdominal pain, and dyspepsia. Esophageal, gastric, or duodenal irritation, perforation, ulceration, or bleeding may occur when administration directions are not followed or when bisphosphonates are prescribed for patients with contraindications. The most common adverse effects of IV bisphosphonates include fever, flu-like symptoms, and local injection-site reactions. Osteonecrosis of the jaw occurs rarely if it develops, oral chlorhexidine washes, systemic antibiotics, and systemic analgesics are used based on severity. 

Ulcer- Gastric or duodenal ulcer with bleeding or perforation (mefenamic acid). 

Perforated duodenal ulcer disclosing medium chain acyl-CoA dehydrogenase deficiency. 

Uhler ML, Budinger GR, Gabram SG, Zinaman MJ. Perforated duodenal ulcer associated with ovarian hyperstimulation syndrome Case Report. Hum Reprod 2001 16(l) 174-6. 

In 1972 we found that injections of propionitrile (Figure 1) consistently produced solitary, often perforating duodenal ulcers in the rat (5.). These lesions occurred 3-5 mm from the pylorus of the stomach, mostly - as in humans - on the anterior wall of the duodenum. The ulcers developed 24-48 h after the initial administration of propionitrile and frequently penetrated into the liver or pancreas ( ). 

The lesion in the duodenum developed even more rapidly (e.g., perforation in 24 h after a single dose) and more predictably than with propionitrile. Acetanilide was the first aryl chemical noted to cause duodenal ulcer ( 18). Subsequently, 3,4-toluenediamine ( ) and 3,4-toluenedithiol (20) were also shown to induce duodenal ulcers and occasionally adrenal necrosis in rats. 

The groups consisted of 3-4 Sprague-Dawley female rats (160-180g). Each experiment was repeated at least twice and the results of those groups were pooled. The dopamine agonists MDO-NPA and NPA were injected sc once daily for seven days prior to the administration of cysteamine HC1 (Aldrich) 28 mg/100 g po three times with 3 h intervals. The dopamine antagonists NCA and (+)butaclamol were injected sc three times, 30 min before each dose of cysteamine. The animals were killed 48 h after the duodenal ulcerogen. The intensity of duodenal ulcer was evaluated on a scale of 0-3, where 0 = no ulcer, 1 = superficial mucosal erosion, 2 = transmural necrosis, deep ulcer, 3 = perforated or penetrated duodenal ulcer. 

Circunstantial evidence directly implicating dopamine in the pathogenesis of duodenal ulcer in man is the unusual incidence of peptic ulcer disease in dopamine-deficient disorders. From purely descriptive clinical and epidemiologic studies we know that patients with Parkinson s disease, before the introduction of dopamine therapy, had an excess of ulcer disease (72). One report even comments on the curiosity that after initiation of L-DOPA administration the ulcer symptoms have virtually disappeared (72 ). On the other hand, less clearly, schizophrenia which is associated with dopamine excess and/or receptor hyperactivity is accompanied by virtual lack, or decreased prevalence, of peptic ulcer (73-76). Schizophrenia associated with ulcer disease has been viewed as a reportable curiosity in medical literature (75). At present, possibly because of the widespread therapeutic application of neuroleptics, the lack of peptic ulcer disease in schizophrenics is less striking than in the past. On the other hand, we recently observed in our autopsy series perforated duodenal ulcers in two schizophrenic patients who had been on large doses of haloperidol therapy (Szabo, unpublished observation). Thus, even in man, dopamine may indeed be implicated in the pathogenesis of duodenal ulcer disease. 

All NSAIDs have the potential to cause gastric and duodenal ulcers and bleeding through direct (topical) or indirect (systemic) mechanisms. Risk factors for NSAID-associated ulcers and ulcer complications (perforation, gastric outlet obstruction, GI bleeding) include increased age, comorbid medical conditions (e.g., cardiovascular disease), concomitant corticosteroid or anticoagulant therapy, and history of peptic ulcer disease or upper Gl bleeding. 

Other reported adverse effects include acute pleuropericardial effusions, perforated duodenal ulcer, acute myositis and pulmonary infiltrates, vascuhtis with pulmonary infiltrates and jaundice, influenza-like illnesses, chest pain, headache, dizziness, anxiety, maculopapular rash, and night sweats (6). 

Pancreatitis, any cause (P-AMY T) Pancreatic trauma (P-AMYT) Biliary tract disease (P-AMYT) - Intestinal obstruction (PtAMYT) Mesenteric infarction (P-Alv4Y(t Perforated peptic ulcer (P-AMYiT) Gastritis, duodenitis (P-AMY ) Ruptured aortic aneurysm Acute appendicitis Peritonitis Trauma... 

In another survey conducted by the clinical section of the British Pharmacological Society over a one-year period from 1986 to 1987, 8163 healthy volunteers received drugs for research purposes.Potentially life-threatening adverse effects were reported in 0-04% and moderately severe adverse effects in 0-55%, with no lasting sequelae. The three severe reactions were skin irritation and rash requiring hospitalisation, anaphylactic shock after an oral vaccine, and perforation of a duodenal ulcer after multiple-dose non-steroidal anti-inflammatory drug all made a complete recovery. The results were similar to those reported in the earlier ABPI survey and the authors concluded that the risk involved in these studies is very small... 

The toxicity of acute iron poisoning includes local effects on the gastrointestinal mucosa and systemic effects induced by excessive iron in the body. Iron is irritating to the gastric and duodenal mucosa, which may result in hemorrhage and occasional perforations. Once... 

Ulcer-related perforation into the peritoneal cavity occurs in about 7% of patients with PUD. The incidence of perforation is increasing with the increased use of NSAIDs. Mortality is usually higher for perforated gastric ulcer than duodenal ulcer. The pain of perforation is usually sudden, sharp, and severe, beginning first in the epigastrium, but quickly spreading over the entire abdomen. Most patients experience ulcer symptoms prior to perforation. However, older patients who experience perforation in association with NSAID use may be asymptomatic. Penetration occurs when an ulcer burrows... 

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