LAPAROSCOPIC GRAHAM PATCH FOR PEDIATRIC DUODENAL PERFORATION

Objectives: Peptic ulcer disease causing perforation is extremely rare in children, and primarily affects teenagers. Here, we describe the case of a 6-year-old that had two weeks of intermittent abdominal pain, and three days of nausea and vomiting. He underwent workup for appendicitis at another facility and was found to have a leukocytosis of 17, elevated anion gap metabolic acidosis, nondiagnostic ultrasound, and a CT revealing moderate volume pneumoperitoneum and pelvic free fluid without a distinct cause. He was emergently transferred, found to be peritonitic, and taken to the operating room for diagnostic laparoscopy, which revealed yellow-tinged ascites, and omentum densely adherent to the duodenum. This was peeled back revealing an anterior duodenal ulcer, and a laparoscopic Graham patch repair was performed. Postoperatively, the child had positive fecal antigen for H. pylori. He was treated with triple therapy and will undergo EGD 6-8 weeks postoperatively to rule out additional pathology. The child’s family received counselling to get tested, throw away toothbrushes, and to be careful with shared household items like dishes and silverware. H. pylori is an important entity to recognize as a cause of pediatric peptic ulcer disease, largely due to its risk of recurrence. Other less common causes of pediatric peptic ulcer disease include NSAID use, Crohn’s disease, CMV, gastrinoma, and hyperparathyroidism. Perforated peptic ulcer is an uncommon pediatric surgical problem, and imaging may not be diagnostic as in the case presented here. Thus, clinicians need to maintain a high index of suspicion when evaluating children with free air and a surgical abdomen in the setting of long-standing abdominal pain.

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