Asymptomatic free intraperitoneal gas with duodenal stenosis

A 30-year-old man was referred to our hospital in October 2006 for asymptomatic free air in the peritoneal cavity found on a plain chest X-ray on a routine health examination. Esophagogastroduodenoscopy (EGD) revealed an ulcer scar and deformity of the duodenal bulb, a healing-phase ulcer in the anterior wall of the upper gastric corpus, grade B esophagitis (Los Angeles grading system), and a sliding hiatal hernia. A test for Helicobacter pylori was negative. Upon obtaining an informed consent (asymptomatic perforation), laparoscopic selective proximal vagotomy, Toupet fundoplication, and small skin incision Finney pyloroplasty were performed. Intraoperatively, extensive adhesions of the greater omentum to the duodenal bulb were found, which were suspected to engulf the cryptic perforation. The patient's postoperative course has been uneventful and, at present, recurrence of the ulcer has not been observed. The presented case is rare considering the absence of surgical history, lack of symptoms, and incidental finding of the intraperitoneal free air during a health examination.