Discussion and Conclusion
The unusual presentation of this patient raised an important question regarding her dual pathology: which occurred first? Did she have a perforated duodenal ulcer, causing sepsis and hypotension leading to small bowel ischemia, or did she suffer from ischaemic bowel, and subsequently developed a stress-related perforated ulcer?
After performing a through literature search, we did identify a single case report that described a patient presenting with acute abdomen and the subsequent intervention revealed exactly the same double pathology of Small bowel ischaemia and duodenal ulcer. However the histopathology of the bowel in that particular case did show evidence of polyarteritis nodosa explaining the cause of the acute bowel ischaemia.[10]
In order to explain this double pathology it is vital to note that in peptic ulcer disease the two major precipitating factors are Helicobacter pylori infection and non-steroidal anti-inflammatory drugs (NSAIDs). Ulcer incidence increases with age and therapy with drugs such as corticosteroids, anticoagulants and bisphoshonates. Complications (bleeding, perforation, obstruction) can occur in patients with peptic ulcers of any aetiology. Perforation occurs in about 5% to 10% of patients with active ulcer disease.[11]
With this background we are proposing two explanations for this pathology. The first is that the patient had been on long term bisphosphonates and this increased her risk for peptic ulcer disease. If we assume that the perforation of the duodenal ulcer occurred first, it was likely that it led to mesenteric venous thrombosis causing ischaemic infarction of the small bowel. The histology results favour this theory as the patient had segmental involvement of the small bowel with the sparing of the large bowel and this commonly present in acute ischaemia of the bowel that is associated with mesenteric venous thrombosis.
The second hypothesis is that the patient developed a stress related duodenal ulcer post ischaemic bowel infarction and eventually this ulcer perforated. The cause of the ischaemia is likely due to arterial thrombosis with a background of severe atherosclerotic disease caused by the patient's long history of hypertension and smoking. Patients with this type of bowel ischaemia present later as they can tolerate major visceral artery obstruction because the slow progressive nature of atherosclerosis allows the development of important collaterals. The patient had 3 days history of feeling unwell and constipation with minimal urine output before she collapsed.
BMC Surg. 2012;12(21) © 2012 BioMed Central, Ltd.
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