Occult Perforation at the Ligament of Treitz in a Patient with Cirrhosis: A Case Report and Literature Review

Abstract

Background: Small intestine perforations in adults occur usually as a result of obstruction and ischemia, hernia strangulation, or trauma. When patients are found to have small intestine perforations, the location of the defect is commonly described as the distance from the ligament of Treitz, which is the suspensory ligament of the duodenum that landmarks the duodenojejunal junction. Few cases exist in which perforations occur right at the ligament of Treitz. Here, we report a rare case of an occult small intestine perforation at the ligament of Treitz in a patient with cirrhosis. Case Presentation: A 75-year-old Caucasian male with Child-Pugh class B alcoholic cirrhosis presented to the emergency department with acute abdominal pain caused by a recurrent umbilical hernia. On physical examination, he had a moderate amount of ascites and a tender mass to the right of the umbilicus. The patient was taken to the operating room (OR) for open reduction and umbilical repair. A fat-containing hernia with a small defect was reduced and 2.5 L of clear ascites was drained. Six hours after the surgery, the patient developed abdominal pain and bilious content began to drain. With differential diagnosis of inadvertent enterotomy or duodenal ulcer perforation, he was urgently taken back to the OR. No clear perforation was found: There was no duodenal ulcer, no diverticular perforation, and no inadvertent enterotomy. An intra-operative gastroscopy was undertaken and an intra-abdominal water test was performed with air insufflation. Bubbling was observed from a 5 mm perforation at the ligament of Treitz. The location of the perforation and its distance from the hernia repair excluded the possibility of iatrogenic perforation. Conclusion: This case is a reminder to examine the ligament of Treitz when searching for a perforation and that the use of intra-operative endoscopy can be useful in diagnosing occult intestinal perforations.Copyright ©2016 Stephanie N. Pilieci et al.