Sharique Nazir, MD, Marcia Chung, MD, Veshal Malhotra, Armand Asarian, MD, , FACS, Peter Pappas, MD, FACS, Fausto Vinces, DO, FACOS
Lutheran Medical Center ,Brooklyn,New York .The Brooklyn Hospital Center ,Brooklyn,New York
Peptic ulcer disease (PUD) during pregnancy is very uncommon ranging from 1-6 in every 23,000 pregnancies. This rarity stems from the protective physiologic changes during pregnancy as well as maternal avoidance of ulcerogenic factors such as alcohol and cigarette smoking. Helicobacter pylori, NSAIDS, and stress are known risk factors for PUD, but the predisposing factors in pregnant females who develop PUD in post-partum period remains an enigma. We present a case of a young patient with no past history of PUD, who developed duodenal perforation in puerperium and required emergent surgery.
A 24 year old primiparous female with no significant past medical presented to the Emergency Room on the 8th post-partum day with acute abdominal pain lasting for five days. The abdominal pain was noted to be dull and intermittent and she had associated non-bilious vomiting. Two days prior to the onset of the pain, the patient had delivered a healthy baby girl via normal spontaneous vaginal delivery. The pregnancy had been uneventful with no documented signs of hypertension or seizures. On admission, the patient was noted to be in acute distress with diffuse abdominal rebound tenderness. A chest x-ray showed free air under the diaphragm and a computed tomography scan (CT Scan) with contrast was ordered. The CT Scan of the abdomen and pelvis revealed pneumoperitoneum with extravasation of contrast along the duodenum extending into the Morrison’s pouch with a filling defect in the duodenum, consistent with a perforation of the duodenum. The patient was taken for emergent exploratory laparotomy. While running the bowel, the surgeons were able to identify an anterior perforation of the duodenum. A Graham Roscoe patch repair was performed and the patient was started on a proton pump inhibitor (PPI) infusion. The patient was discharged home after clinical improvement on the PPI.
The puerperal abdomen often has the reduced ability to respond to peritoneal irritation due to the stretched abdominal musculature. The anterior abdominal wall is often stretched and elevated during pregnancy and therefore the underlying inflammation often fails to exert parietal peritoneal irritation. Even after delivery, the relaxed and thinned abdominal muscles may not respond actively with guarding or board-like rigidity often seen with peritoneal inflammation. A high degree of clinical suspicion must be used to properly assess abdominal pain in a puerperium female even though non-specific abdominal pain is experienced postpartum by 98% and 92% of primiparous and multiparous women respectively. This pain is generally a result of the stresses on the uterus during labor and can be aggravated by breastfeeding, which causes the uterus to contract further. However, anything other than intermittent mild colicky lower abdominal pain is abnormal and careful analysis must be taken. The relative rarity of a perforated duodenal ulcer in the puerperium period as well as the attribution of clinical signs to obstetric related causes can delay diagnosis and intervention, which can often lead to mortality.
Session: Poster Presentation
Program Number: P227