Perforated marginal ulcers - what are the surgical options - simple closure or is definitive surgery needed? A case...

Marginal ulceration is an uncommon complication following gastrojejunostomy. Perforation of such ulcers is rare but potentially life-threatening, particularly in the era of widespread proton pump inhibitor use.

We report a 54-year-old man and heavy smoker who presented with acute abdominal pain and vomiting, 3 years after an open gastrojejunostomy performed for a complicated duodenal ulcer. Clinical examination revealed diffuse epigastric tenderness and signs of peritonitis. Laboratory tests showed leukocytosis. Abdominal CT revealed pneumoperitoneum near the gastrojejunostomy, suggesting a perforated marginal ulcer. The patient underwent emergency laparotomy, which confirmed a 1-cm perforation on the jejunal side. Primary closure was performed. Postoperatively, he received proton pump inhibitors and Helicobacter pylori eradication therapy. Recovery was uneventful.

The role of H. pylori remains unclear. Perforation presents with sudden, severe epigastric pain and may lead to shock. CT imaging is the preferred diagnostic modality, although the perforation site may not always be visible. While laparotomy is standard for unstable patients, laparoscopy may be considered in stable cases. In non-bariatric surgery, primary closure or omental patch repair is often sufficient, reducing the morbidity associated with anastomotic revision. Truncal vagotomy, now performed rarely, provides a definitive reduction in gastric acid secretion and may be considered in patients who are non-compliant with medical therapy.

Perforated marginal ulcer is a rare but serious complication. Prompt diagnosis and surgical management are critical. In selected cases, primary closure or omental patch repair is effective, with postoperative acid suppression essential to prevent recurrence.