Perforated duodenal ulcer after perioperative steroid treatment.

A fit 23-year-old housewife with primary infertility was first treated in 1978 by the operation of bilateral salpingostomy to correct hydrosalpinges. Having failed to conceive within two years, she was referred to a second hospital where in June 1980 laparoscopy showed a right hydrosalpinx with gross fimbriovarian adhesions. The left Fallopian tube appeared patent, but there was kinking at the ampulla and adhesions over the left ovary. It was decided that her chances of conception would be improved by a second attempt at tubal surgery. Therefore a laparotomy was performed in October through a Pfannenstiel incision. There were no signs of active peritonitis, although the upper abdomen was not palpated. Using a microscope and microsurgery salpingolysis and ovariolysis and plication of the round ligament were performed on the left side. No reconstructive surgery was thought to be feasible on the right side. During the operation 1-5 g of hydrocortisone in solution was instilled into the pelvis and 100 mg of Hydrocortisone Hemisuccinate was given intravenously. She was given dexamethasone 2 mg four times a day on the first postoperative day; 1 5 mg three times a day on day 2; 1 mg four times a day on day 3; and 0 5 mg four times a day for four days thereafter. She was also prescribed ampicillin 500 mg four times a day and metronidazole 200 mg three times a day for one week. Postoperative analgesia was provided by two doses of intramuscular papaveretum 15 mg and a total of 14 tablets of dextropropoxyphene over the first three days. She made an uneventful recovery, apart from nausea and vomiting for the first four days despite normal bowel sounds and the passage of flatus on the second post-operative day. At no time did the vomitus contain blood or coffee grounds. Her temperature chart remained normal, and she had a bowel action on the fifth post-operative day. She was discharged home on the seventh day; this was earlier than normal but she was becoming distressed because her husband could not visit regularly as he lived too far away from the hospital. While travelling home she Patients who are given steroids during abdominal surgery to prevent adhesions occurring may develop a perforated duodenal ulcer