BACKGROUND: Posterior perforation of peptic ulcer is a distinct clinical entity not commonly encountered. This report evaluates the presentation, diagnosis, management, and outcome of this acute surgical condition. METHODS: We reviewed records of 9 patients with posterior perforations who were treated at our institution from January 1990 to June 2002. RESULTS: This condition was characterized by insidious onset of upper abdominal pain and delayed presentation. Abdominal examinations were equivocal in 7 patients on admission. Pneumoperitoneum on chest roentgenogram, when present, was a crucial diagnostic indicator of intra-abdominal pathology. The diagnosis was made intraoperatively in all cases; findings were sealed perforation, localized retroperitoneal abscess, or generalized contamination of the lesser sac and peritoneal cavity. Observed adverse operative risk factors included prolonged perforation (>24 hours), pre-existing chronic medical illnesses, and preoperative hypotension. In addition, significant peritoneal contamination at celiotomy, major resection (gastrectomy), and gastric perforations were noted to be associated with a poor outcome: 4 of the 9 patients died. CONCLUSION: A high index of suspicion is important. When a retroperitoneal collection is noted at celiotomy, posterior perforation of peptic ulcer should be actively excluded.
BACKGROUND: Posterior perforation of peptic ulcer is a distinct clinical entity not commonly encountered. This report evaluates the presentation, diagnosis, management, and outcome of this acute surgical condition. METHODS: We reviewed records of 9 patients with posterior perforations who were treated at our institution from January 1990 to June 2002. RESULTS: This condition was characterized by insidious onset of upper abdominal pain and delayed presentation. Abdominal examinations were equivocal in 7 patients on admission. Pneumoperitoneum on chest roentgenogram, when present, was a crucial diagnostic indicator of intra-abdominal pathology. The diagnosis was made intraoperatively in all cases; findings were sealed perforation, localized retroperitoneal abscess, or generalized contamination of the lesser sac and peritoneal cavity. Observed adverse operative risk factors included prolonged perforation (>24 hours), pre-existing chronic medical illnesses, and preoperative hypotension. In addition, significant peritoneal contamination at celiotomy, major resection (gastrectomy), and gastric perforations were noted to be associated with a poor outcome: 4 of the 9 patients died. CONCLUSION: A high index of suspicion is important. When a retroperitoneal collection is noted at celiotomy, posterior perforation of peptic ulcer should be actively excluded.