A unique presentation of perforated duodenal ulcer in a post
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Gallbladder disease and peptic ulcer disease (PUD) can present very similarly, and misdiagnosis can often result because of conflicting symptoms. Peptic ulcer disease in pregnancy is relatively rare, in part due to the changes in estrogen and progesterone levels. here present a case of a postpartum female, post-operation Day 5, with signs/symptoms, physical exam, and laboratory work consistent with acute cholecystitis that was found to have a perforated duodenal ulcer intraoperatively. The authors suggest that a fistula would have resulted in the ongoing disease. All of the standard preoperative measures were taken and the patient was prepped and draped for laparoscopic cholecystectomy. Ports were placed in a typical fashion for this operation, with A 12 mm Hasson trocar placed in a supraumbilical position, and 5 mm trocars placed in the epigastrium and RUQ x2. Upon insertion of the laparoscope, the uterus was still large in the pelvis and there was a small amount of bloody fluid in the abdomen. The fundus of the gallbladder was grasped and retracted cephalad. With this maneuver, it appeared that the duodenum had fused itself to the infundibulum of the gallbladder.

Upon gently peeling the duodenum off of the gallbladder, it became obvious that there was a perforated duodenal in the first portion of the anterior duodenum and had been the gallbladder that sealed the perforation. The gallbladder showed signs of erosion at the site where it patched the duodenum as well. At this time we proceeded with laparoscopic cholecystectomy first, prior to addressing the duodenum. Once successfully completed with the cholecystectomy, we performed a laparoscopic graham patch with our existing ports. A #10 flat JP was inserted in the region of the graham patch. The abdomen was irrigated and then suctioned clean. The repair was confirmed by placing underwater with the second portion of the duodenum compressed, while anesthesia insufflated the stomach/duodenum through an OG tube. The patient tolerated the operation well, extubated, and transported to recovery.

Cholecystoduodenal fistulas (CDFs) are the most common fistulas to present. It is possible that the incidence of CDF formation secondary to perforated duodenal ulcers is underestimated due to signs and symptoms not presenting until gallstone ileus is diagnosed.