A 36-year-old previously healthy male presented to the emergency department with several hours history of sudden epigastric pain which increased gradually to become generalized causing findings of an acute surgical abdomen. His leukocyte counts and septic markers were elevated. A plain chest and abdominal X-ray showed no evidence of pneumoperitoneum or obstruction. Abdominal CT scan however, showed free air in the retroperitonium. After urgent resuscitation, the patient was taken for emergency laparotomy. This revealed a large posterior perforation extending laterally in the first part of duodenum. The duodenum was severely inflamed and the retroperitoneal space was contaminated with purulent discharge and debris. The abdomen was thoroughly irrigated with normal saline, and the patient underwent a Graham’s patch repair to the duodenal perforation, a gastrojejunostomy and insertion of a feeding jejunostomy tube. A closed tube drain was inserted to the right hypochondrium. No definitive repair procedure was performed to avoid prolonging operative time further and it was kept in mind that any further leak which was expected will be managed conservatively because of presence of purulent peritonitis as in such an abdomen any surgical intervention is going to cause more harm than good, so only damage control surgery was done. Post-operatively, the patient developed a high output duodenal fistula which was managed conservatively successfully. Complete closure of the fistula was confirmed by performing a gastrografin study. The patient was discharged home tolerating oral feed on the 35th postoperative day.
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