ABSTRACT 

Perforated gastroduodenal disease remains a time-critical surgical emergency. A postoperative bile leak after repair of an apparently limited pre-pyloric perforation raises concern for an unrecognized biliary or duodenal injury, particularly when initial imaging demonstrates pneumobilia, biliary dilatation, and inflammatory changes around the duodeno-pancreatic junction.
A 56-year-old chronic smoker presented with four days of epigastric pain, abdominal distension, tympanism, and epigastric guarding. Computed tomography showed an apparent antro-pyloric perforation, pneumobilia, air bubbles around the duodeno-pancreatic junction, biliary dilatation, and a distended sludge-filled gallbladder. Emergency laparoscopy found a 5mm pre-pyloric perforation, which was sutured with omental patching and drained. Early postoperative bile output through the subhepatic drain, persistent inflammatory markers, and repeat CT with water-soluble contrast demonstrated a suspected second perforation at D1. Emergency reoperation revealed bile in the subhepatic space, extensive fibrinous membranes, and a D1 perforation. Antegrade cholecystectomy, interrupted 3/0 polyglactin closure of the D1 defect, feeding jejunostomy, extensive peritoneal lavage, and multiple drains were performed. This case highlights the diagnostic difficulty of overlapping gastroduodenal and biliary pathology and the importance of interpreting postoperative bile drainage as a potential marker of an occult duodenal defect. Early cross-sectional reassessment and prompt source control are central to management.

KEYWORDS

Perforated peptic ulcer ; Duodenal perforation ; Bile leak ; Pneumobilia ; Cholecystectomy ; Emergency surgery ; Laparoscopy.
 

REFERENCES

1) Tarasconi A, Coccolini F, Biffl WL, et al. Perforated and bleeding peptic ulcer: WSES guidelines. World J Emerg Surg. 2020;15:3. doi:10.1186/s13017-0190283-9.
2) Sohrabi C, Mathew G, Maria N, et al. The SCARE 2023 guideline: updating consensus Surgical CAse REport (SCARE) guidelines. Int J Surg. 2023;109:1136-1140. doi:10.1097/JS9.0000000000000373.
3) Sokhal BS, Mohamedahmed A, Zaman S, et al. Laparoscopic versus open repair for peptic ulcer perforation: a systematic review, meta-analysis and trial sequential analysis of randomised controlled trials. Ann R Coll Surg Engl. 2025;107(5):331-345. doi:10.1308/rcsann.2024.0082.
4) Chalmers KA, Lee MJ, Cousins SE, et al. Laparoscopic versus open repair of perforated peptic ulcer: systematic scoping review and in-depth evaluation of existing evidence. BJS Open. 2025;9(2):zrae163. doi:10.1093/bjsopen/zrae163.
5) Patel PY, Akhani MK, Rathod R, Baria B. Post-operative outcomes of laparoscopic versus open repair of perforated duodenal ulcer: a systematic review. Cureus. 2025;17(9):e92021. doi:10.7759/cureus.92021.
6) Panin SI, Nechay TV, Sazhin IV, et al. Laparoscopic suture repair for perforated peptic ulcer disease: a meta-review and trial sequential analysis. Front Surg. 2025;12:1496192. doi:10.3389/fsurg.2025.1496192.
7) Agha RA, Fowler AJ, Saeta A, et al; SCARE Group. The SCARE statement: consensus-based surgical case report guidelines. Int J Surg. 2016;34:180186. doi:10.1016/j.ijsu.2016.08.014.
8) Agha RA, Borrelli MR, Farwana R, et al; SCARE Group. The SCARE 2020 guideline: updating consensus Surgical CAse REport (SCARE) guidelines. Int J Surg. 2020;84:226-230. doi:10.1016/j.ijsu.2020.10.034.
9) Gagnier JJ, Kienle G, Altman DG, et al. The CARE guidelines: consensus-based clinical case reporting guideline development. Headache. 2013;53:1541-1547. doi:10.1111/head.12219.
10) Kafih M, Fekak H, El Idrissi A, Zerouali NO. Perforated duodenal ulcer: laparoscopic treatment of perforation and ulcerous disease. Ann Chir. 2000. doi:10.1016/S0001-4001(00)00132-X.

Cite this article

Abdelhak, E., Mahassine, R., Hajar, M., Ichrak, B., Khadija, K., Abdessamad, M., Mounir, B., Abdelillah, E. B., & Khalid, E. H. (2026). Sequential Postoperative Bile Leak Following Laparoscopic Repair
of Pre-Pyloric Perforation Revealing a Concomitant Duodenal Perforation: A Case Report. INTERNATIONAL JOURNAL OF HEALTH & MEDICAL RESEARCH, 5(10), 1019-1024. https://doi.org/10.58806/ijhmr.2026.v5i10n05