Perforated Duodenal Ulcer 24 Years After Roux-en-Y Gastric Bypass: A Rare Presentation With Pneumoperitoneum.

Perforated duodenal ulcers post Roux-en-Y gastric bypass (RYGB) are rare, with fewer than 30 documented cases. Diagnosis can be challenging due to the absence of pneumoperitoneum on cross-sectional imaging, seen in only five published cases.  A 67-year-old female patient, 24 years post RYGB, presented with diffuse abdominal pain, fever, hypotension, and tachycardia following recent nonsteroidal anti-inflammatory drugs (NSAIDs) use. Laboratory findings showed leukopenia and elevated lipase. Computed tomography (CT) imaging revealed pneumoperitoneum, prompting emergent exploratory laparotomy. A 0.5 cm duodenal perforation was identified and repaired with omental plication. Postoperatively, the patient developed bacteremia and intra-abdominal abscess requiring prolonged antibiotics and percutaneous drainage. Empiric () treatment and lifelong proton pump inhibitors (PPI) were initiated. No standard treatment exists for post-RYGB duodenal perforation, though omental patch plication is commonly performed. Some advocate for complete gastrectomy to prevent ulcer formation; however, risks of doing so include dysmotility, bacterial overgrowth, and recurrent ulceration. Theories regarding the etiology of these ulcers include persistent acid production in the remnant stomach, infection, and potential NSAID-related effects. Lifelong PPI use, clinical monitoring for recurrent ulcers, and early endoscopy in symptomatic patients constitute long-term patient management. While routine surveillance endoscopy is not standard, it may be considered in high-risk patients such as those with poor nutrition, ulceration while on PPI, or current smokers.