Acute cholecystitis is a common surgical emergency arising from gallstone disease. It is usually treated with rest, antibiotics and cholecystectomy, which can be immediate or delayed.
Perforated peptic ulcer is one of the complications of peptic ulcer disease and is still a common surgical emergency, though the incidence has decreased dramatically with the use of proton pump inhibitors. Usually upper gastrointestinal perforations present with an acute abdomen with features of peritonitis. Perforations are usually repaired though can be treated conservatively. Without surgery the natural history is for the perforation to become sealed off by surrounding structures (usually the omentum). Although upper gastrointestinal perforations are sometimes treated conservatively these tend to be in older patients who may not do well with an operation. Repair may be open or laparoscopic.1,2
Despite the two pathologies being very common there is little in the literature about the two pathologies coexisting. A previous case series has shown seven cases of perforated duodenal ulcer found during laparoscopic cholecystectomy in a retrospective study of 5539 patients who had undergone laparoscopic cholecystectomy for gallstone disease in a single unit.3
No other cases were found in the literature.
The case presented here is an unusual presentation of a pyloric perforation. It is possible that this was an incidental finding. However, the perforation was large and it is surprising if this did not cause symptoms itself. It is difficult to tell which caused the presentation, especially as the histology showed acute inflammation in both the pyloric biopsies and the gallbladder. However, it is possible that it was the cause of the presentation and was masquerading as cholecystitis. This case demonstrated how well the body can seal off such substantial perforations.
The case reminds us of the need to know how to deal with unexpected findings at laparoscopy. It reminds us that it is necessary to train ‘general surgeons’ in the world of super-specialisation.
- It is important not to be led entirely by scans and to use clinical judgment when making a diagnosis of acute cholecystitis.
- Upper gastrointestinal perforations may not always present with peritonitis.
- Multiple pathologies may be found at operation.
- It is important to be able to deal with the unexpected at operation.