Posterior perforation of peptic ulcers: presentation and outcome of an uncommon surgical emergency.

BACKGROUND Posterior perforation of peptic ulcer is a distinct clinical entity not commonly encountered. This report evaluates the presentation, diagnosis, management, and outcome of this acute surgical condition. METHODS We reviewed records of 9 patients with posterior perforations who were treated at our institution from January 1990 to June 2002. RESULTS This condition was characterized by insidious onset of upper abdominal pain and delayed presentation. Abdominal examinations were equivocal in 7 patients on admission. Pneumoperitoneum on chest roentgenogram, when present, was a crucial diagnostic indicator of intra-abdominal pathology. The diagnosis was made intraoperatively in all cases; findings were sealed perforation, localized retroperitoneal abscess, or generalized contamination of the lesser sac and peritoneal cavity. Observed adverse operative risk factors included prolonged perforation (>24 hours), pre-existing chronic medical illnesses, and preoperative hypotension. In addition, significant peritoneal contamination at celiotomy, major resection (gastrectomy), and gastric perforations were noted to be associated with a poor outcome: 4 of the 9 patients died. CONCLUSION A high index of suspicion is important. When a retroperitoneal collection is noted at celiotomy, posterior perforation of peptic ulcer should be actively excluded.