The more serious complications of duodenal ulcer, aside from hemorrhage, are those of perforation, cicatricial contractions or stricture formation (obstructing the bowel or the common duct, or both), local peritonitis, cancer, and indirectly gall-bladder or pancreatic disease. Next to hemorrhage perforation is more likely to occur in a duodenal than in a gastric ulcer and with more disastrous consequences. Such perforation affords a peculiar mimicry of acute, gangrenous appendicitis which, as Moynihan has shown, is due to the direction taken by the extravasated fluid down along the right of the transverse mesocolon toward the iliac fossa. In fact, the condition is more likely to be mistaken for one of acute appendicitis than for anything else.
With a primary ulcerative lesion in the duodenum it is easy to realize that infection may readily travel up the common duct, involving both the pancreas and the biliary passages, while the resulting cholecystitis will intensify and spread the local peritonitis previously produced, and all combined will cement the viscera in this region into one common mass in which anatomical identity is easily lost. A good history, when obtainable, will help very much in diagnosis, especially when the absence of previous gastric symptoms can be established. This, with the symptoms already given above, and the tenderness over the duodenum, which is rarely absent, will afford good basis for diagnosis in the more chronic cases. Duodenal perforation may even be mistaken for rupture of an extra-uterine pregnancy, as well as for perforation of the stomach or of the gall-bladder, or, as mentioned above, of an appendix.
Quite recently attention has been called to a condition of the duodenum resembling that known as hour-glass stomach, and produced in much the same way. It seems to be the result of cicatricial contraction of an old ulcerated area, and may cause almost complete constriction. Hour-glass duodenum is amenable to surgery only, and should be treated either by gastrojejunostomy or possibly by a resection with end-to-end suture.
Treatment.
—For duodenal ulcer when recognized before perforation, there is but one treatment, i. e., gastro-enterostomy, preferably posterior, performed exactly as for gastric ulcer, for the same reason, and with the same prospect of relief, inasmuch as it affords physiological rest for the diseased area. In rare instances it may be possible to so expose the duodenum as to make it justifiable to attack the ulcer directly, but the simplest and, in general terms, the best procedure is that just mentioned.
For perforated ulcer of the duodenum the indication is not alone for a gastro-anastomosis, but for exposure of the site of perforation, removal of all extravasated material, a most careful toilet of the peritoneum, and suture of the perforated area, this being the indication when possible. Provision should be made for drainage, while at the same time affording a direct outlet from the stomach into the first portion of the jejunum beyond. Should the surgeon operate apparently for appendicitis and discover that he has to deal with a perforated duodenum he should extend far upward the incision made for the former purpose, and, having thus widely opened the abdomen, should thus find himself perhaps better provided with space in which to work than had he opened at first directly over the duodenum.
Typhoidal Ulcers.
—Typhoidal ulcers of the intestines have a tremendous surgical interest in that they not infrequently lead to perforation, and that this almost always is fatal if let alone. It may be possible, however, by prompt recognition of the occurrence of the perforation and by immediate intervention to cleanse the peritoneal cavity of extravasated feces and close the opening thus made.
Symptoms.
—The symptoms of perforation are at first not unlike those of hemorrhage, in that shock is immediate and profound, and pain, usually intense, is produced. These are quickly followed by abdominal rigidity, while a blood count will show a rapidly increasing and high leukocytosis. To the expressions of local peritonitis are quickly added those of one which is generalized, with well-marked rigidity and great meteorism.