Duodenal perforation in children: must surgery be performed?

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Xiang Wang, Weijun Zheng, Fei Chen, Dianming Wu, Yifan Fang, Mingkun Liu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3894604/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective： The aim of this study is to share our experience in the conservative treatment of duodenal perforation in children. Method： Retrospective collection of clinical data on 6 children with duodenal perforation treated at Fujian Children's Hospital from May 2022 to October 2023. Six cases were all males, ranging in age from 8 to 14 years old, and the onset time ranged from 4 to 24 hours. Main manifestations are abdominal pain, vomiting, fever, etc. Among them, 5 children have undergone abdominal CT examination at local hospitals, indicating gastrointestinal perforation. Result： All 6 patients were diagnosed with perforation of the anterior wall of the duodenum, of which 5 cases were confirmed by ultrasound examination to be located in the bulb, and 1 case was located at the junction of the bulb and the descending part. The perforation diameter of all cases was less than 1cm.Four of them were less than 5mm, and 1 case was 6.9mm. Abdominal X-ray plain film showed 3 cases of free gas downstream of the diaphragm. Five cases underwent conservative treatment, including fasting, gastrointestinal decompression, antibiotics, proton pump inhibitor (PPI), octreotide, and nutritional support. Blood routine monitoring showed that white blood cell (WBC) count and C-reactive protein (CRP) level gradually returned to normal. They recovered after 10-16 days of hospitalization. One case underwent emergency laparoscopic repair of duodenal perforation due to sepsis after 2 days of conservative treatment. Complications such as chyloperitoneum, pleural effusion and subphrenic effusion occurred after the surgery, and the patient recovered after 34 days of hospitalization. All patients recovered and were discharged. Continue to take omeprazole acid therapy for 8 weeks after discharge. All cases were followed up for a period of 1 month to 1 year. Only 1 patient underwent gastroscopy 3 months later and, diagnosed with multiple duodenal ulcers (S2 stage), and continued treatment. The remaining 5 cases showed no signs of second time perforation, bloody stools, abdominal pain, or vomiting. Conclusion： Duodenal perforation in children is rare and often caused by primary ulcers. Most of them has a history of chronic abdominal pain, with symptoms of abdominal pain, vomiting, fever, and signs of peritonitis during acute attacks. Abdominal X-ray, abdominal CT plain scan, and ultrasound can assist in diagnosis. As long as there is no progression to sepsis, conservative treatment can achieve the same therapeutic effect as surgical treatment, with satisfactory outcomes and acceptable hospital stay. Duodenal perforation Children Conservative treatment Figures Figure 1 Background Duodenal perforation is a common acute abdominal disease, but it is relatively rare in children. Due to the urgent onset and rapid progression of the disease, surgical treatment is recommended by the mainstream to reduce mortality. But does surgery really have to be done to cure it? Now we collect data on pediatric patients with duodenal perforation admitted to our center from 2022 to 2023 and share their treatment experience based on the results obtained from conservative treatment during the treatment period. Methods There are a total of 6 male patients (Table 1 ) with aged ranging from 8 to 14 years old. Among them, 4 cases have previous abdominal pain, lasting from 1 month to 6 months; Two patients had taken ibuprofen due to COVID-19 infection before the onset, and all patients did not take hormone drugs, alcohol and do not have other diseases. The course of the disease ranges from 4 hours to 24 hours. There were 6 cases of abdominal pain, 3 cases of vomiting, 4 cases of fever, and 1 case of black stool. All of them had signs of peritonitis. Five patients underwent abdominal CT plain scan at local hospitals, which revealed gastrointestinal perforation or subphrenic gas. After visiting our center, blood routine examination, abdominal X-ray plain film, and abdominal ultrasound were immediately improved. Only 3 cases showed subphrenic gas or pneumoperitoneum by their abdominal X-ray plain film. All patients were diagnosed with abdominal ultrasound and the location and diameter of the perforation were determined (Fig. 1 ). There were 4 cases of anterior wall of the ball and 1 case of anterior wall at the junction of the descending part of the ball. Only one case was unable to locate and measure the diameter and was clearly explored during surgery. And all patients' amylase levels are normal. Table 1 Clinical characteristics of patients ID Gender Age(Year) Course of disease(h) Clinical feature CT scan X-ray Perforation site Diameter(mm) 1 Man 8 15 Abdominal pain, vomiting, fever Digestive tract perforation Subphrenic gas Anterior wall of bulb 2 2 Man 12 6 Abdominal pain, vomiting, fever, tarry stool Subphrenic gas Pneumoperitoneum Anterior wall of bulb 1.7 3 Man 9 24 Abdominal pain, fever Subphrenic gas / Anterior wall of bulb 2.5 4 Man 14 4 Abdominal pain Digestive tract perforation Pneumoperitoneum Anterior wall of bulb 2.9 5 Man 12 24 Abdominal pain, fever Digestive tract perforation / Between the bulb and descending part 6.9 6 Man 13 24 Abdominal pain, vomiting,shock None / Anterior wall of bulb 5 Results All patients underwent fasting, nasogastric tube decompression, antibiotics, intravenous nutrition, PPI, and octreotide treatment. During this period, vital signs and changes in abdominal signs were monitored, and blood routine tests were dynamically performed. Among them, 5 patients recovered after conservative treatment. Blood routine and CRP were tested every three days, and the indicators gradually decreased and returned to normal. Gastrointestinal decompression changed from the original yellow green liquid to transparent gastric juice. After the symptoms of peritonitis were alleviated, the nasogastric tube was removed, and ultrasound examination showed that the duodenal perforation healed, restoring a fluid diet. Antibiotics should be treated with a combination of " Cefoperazone Sodium and Sulbactam Sodium " and "Metronidazole" until blood routine tests are normal. Total parenteral nutrition (TPN) support is required during fasting. Gastrointestinal decompression for 3–12 days, fasting for 7–13 days, and hospitalization for 10–16 days. One child developed sepsis after 2 days of conservative treatment, with significantly increased signs of peritonitis and unstable vital signs. Emergency laparoscopic duodenal perforation repair was performed. During the surgery, a perforation was found on the anterior wall of the duodenal bulb, with a diameter of 5mm. After 6 days of postoperative gastrointestinal decompression and 11 days of fasting, duodenography was performed, and no contrast agent overflowed in the duodenum. The fluid quality was restored, and the abdominal drainage volume did not decrease 13 days after surgery. The chyle test was positive after taking ascites, and chyloperitoneum was considered. Follow up ultrasound showed subphrenic and pleural effusion. After treatment with fasting, PPI, octreotide and TPN, ascites gradually decreased and the hospital stay was 34 days. All patients recovered and were discharged. Continue to take omeprazole acid therapy for 8 weeks after discharge. All cases were followed up for a period of 1 month to 1 year. Only 1 patient underwent gastroscopy 3 months later, diagnosed with multiple duodenal ulcers (S2 stage), and continued treatment. The remaining 5 cases showed no signs of re perforation, bloody stools, abdominal pain, or vomiting. Table 2 Outcome of treatment in all cases ID Treatment Fasting(d) decompression(d) Hospitalization length(d) 1 Conservative 12 12 14 2 Conservative 13 3 16 3 Conservative 10 4 15 4 Conservative 8 7 10 5 Conservative 7 5 10 6 Conservative-Surgical 11 6 34 Table 3 Blood routine and CRP change in cases with successful conservative treatment ID 1 2 3 4 5 WBC (10 9 /L) NE% CRP (mg/L) WBC (10 9 /L) NE% CRP (mg/L) WBC (10 9 /L) NE% CRP (mg/L) WBC (10 9 /L) NE% CRP (mg/L) WBC (10 9 /L) NE% CRP (mg/L) 1st 10.39 85 61.3 26.19 94.8 15.55 17.29 92.3 1.19 22.94 92.4 0.53 14.25 83.7 138.19 2nd 5.08 64.2 22.82 7.42 72.7 111.08 5.81 52.1 16.17 13.44 89.4 87.38 8.26 60.5 87.47 3rd 3.88 45.7 5.79 5.77 63.8 49.59 4.45 42.4 7.29 7.91 69.7 30.3 11.05 69.9 37.85 4th 4.16 50.9 14.5 5.33 55.6 1.97 7.65 60 8.6 5th 4.51 35.6 8.41 Discussion Duodenal perforation in children is rare in clinical practice, and the number of reported cases in the literature is also relatively small [ 1 ] . A study has found that the average age of pediatric perforated peptic ulcer is 14.2 years old. 90% of them are adolescents [ 2 ] . In our study, the average age of onset of duodenal perforation in children was 11.3 ± 2.3 years old. The number of males with duodenal ulcer perforation in adults is almost three times that of females [ 3 ] . In our study, all cases were male, which is consistent with their conclusions. The main causes of duodenal perforation include trauma, iatrogenic injury, and gastrointestinal ulcer. The main causes of duodenal ulcer include Helicobacter Pylori (HP) infection, non-steroidal anti-inflammatory drugs(NSAIDs), steroid anti-inflammatory drugs, stress response, gastrinoma, etc. [ 4 – 6 ] . In our study, 4 children have a long history of chronic abdominal pain, of which 2 children used ibuprofen due to COVID-19 infection, and duodenal ulcer lesions were found in color ultrasound examination. Therefore, we highly suspect that these 4 children have a history of duodenal ulcer, but there is no clear history of familial HP infection. In the later follow-up, except for one child who was diagnosed with HP infection after treatment of ulcers in the digestive department, no further investigation was conducted on the status of HP infection. Based on this, a detailed inquiry about medical history, understanding past medical history and medication history, is very helpful for diagnosing the disease. Due to the fact that most of our cases are older children, the description of their own symptoms is relatively clear. Their symptoms are similar to those of adults, with a history of chronic abdominal pain. After acute onset, they experience severe upper abdominal pain, vomiting, fever, and black stools. On physical examination, there are obvious signs of peritoneal irritation (abdominal tenderness, rebound pain, and abdominal muscle tension), but a few cases have severe sepsis and septic shock. Currently, the diagnosis of duodenal perforation in children is not difficult, and commonly used X-ray, abdominal CT scan, and abdominal ultrasound are the main diagnostic methods for duodenal perforation [ 7 ] . When the child has clear symptoms of perforation, they should actively improve the examination. The World Society of Emergency Surgeons (WSES) recommends that for children with suspected gastric or duodenal perforation, abdominal standing X-ray should be taken first. If the result is negative, abdominal CT plain scan should be performed to check for free gas in the abdominal cavity. If it is still negative, oral contrast enhanced CT examination is feasible for a clear diagnosis [ 8 ] . Usually, the abdominal X-ray shows subphrenic gas in an upright position; Abdominal CT scan findings include abdominal fluid accumulation, pneumoperitoneum, and thickening of intestinal wall. However, in our study, X-ray also showed negative results. As reported in the literature, the positive rate of free gas downstream of the diaphragm on abdominal X-ray plain films of duodenal perforation is less than 40% [ 9 ] , which may be related to the smaller diameter of the perforation and less gas entering the abdominal cavity, so negative results cannot be ruled out. Sometimes the family member of patients refuses to do CT scans because of its radiation hazards. Our patients have undergone CT scans at local hospitals to confirm gastrointestinal perforation and are referred to our center for further treatment. For all cases, we arranged experienced color Doppler ultrasound doctors for ultrasound examination, which can also diagnose duodenal perforation [ 10 ] . Ultrasound manifestations include accumulation of gas and liquid around the duodenum, discontinuity of the duodenal wall, surrounding swelling, and abdominal fluid accumulation. Ultrasound examination not only helps us diagnose the cause, but also provides us with key information such as the location and diameter of the perforation. The most common site of digestive tract perforation in children in Europe is the duodenum, mainly located in the anterior wall [ 11 ] . In our case, 5 cases were identified with ultrasound to determine the perforation site. 4 cases were located on the anterior wall of the ball, and 1 case was located on the anterior wall at the junction of the ball and the descending part. The diameter was less than 1cm, with 4 cases being less than 5mm and 1 case being 6.9mm. We suggest that cases with suspected duodenal perforation undergo routine ultrasound examination in order for ultrasound doctors to grasp the ultrasound manifestations of the perforation and improve the examination level. When ultrasound can diagnose perforation, abdominal CT plain scan becomes unnecessary, which can reduce the radiation harm to the child and reduce the financial burden on the family. The mainstream treatment method for duodenal perforation is active surgical intervention. Both in China and internationally, there are many literature introductions on duodenal perforation surgery [ 12 – 14 ] . Duodenal perforation in children is mostly single perforation and can generally be treated with repair. Laparoscopic repair of duodenal perforation has been widely carried out in patients with smaller perforation. If the perforation diameter is large, greater omentum filling repair surgery is feasible [ 14 , 15 ] . The effect of the surgery is also quite good. For example, in our case where conservative treatment failed, emergency surgical repair was performed. Although postoperative complications resulted in an extension of hospital stay, follow-up after surgery was normal. Do all children with duodenal perforation require surgical treatment? The duodenal bulb is enveloped by the peritoneum, with a small perforation diameter and less leakage of intestinal contents, often limited to the peritoneum. Children have strong tissue repair ability and are prone to perforation healing. Duodenal perforation may be filled with fibrin, enveloped by omentum, or spontaneously healed by adhesion to the liver surface through the duodenum [ 16 ] . These are the basic hypotheses for conservative treatment of duodenal perforation in children. Moreover, statistics suggest that approximately 50–70% of patients with peptic ulcer perforation do not require surgery and can receive conservative treatment [ 17 ] . The treatment guidelines in Japan indicate that conservative treatment can be adopted for cases that develop within 24 hours, have stable conditions, and have limited peritoneal irritation. A review of duodenal perforation suggests that conservative treatment is feasible for patients with stable vital signs of perforation. If sepsis or shock occurs, emergency surgery is required. And it summarized the conservative treatment measures: fasting, intravenous infusion therapy, broad-spectrum antibiotics, intravenous PPI, indwelling nasogastric tubes, eradicating Helicobacter pylori, as well as the controversial use of somatostatin [ 7 ] . In addition, some literature on the conservative treatment of postoperative duodenal perforation in children also confirme the safety and feasibility of conservative treatment [ 18 , 19 ] . The onset time of the cases in this study was within 24 hours. Although the symptoms and signs were obvious, their consciousness was clear and their vital signs were stable. Ultrasound found that the perforation was single, mostly located in the anterior wall of the bulb, and the diameter of the perforation was small. Therefore, conservative treatment was adopted. The 5 cases with successful conservative treatment had fasting time of 10.0 ± 2.55 days, gastrointestinal decompression time of 6.2 ± 3.56 days, and total hospitalization time of 13.0 ± 2.83 days. Shen reported that 32 children with duodenal perforation underwent conservative treatment, fasting for 10.3 ± 2.78 days, and a total hospital stay of 14.8 ± 4.60 days [ 20 ] . It can be seen that the recovery time of conservative treatment is similar. To summarize our experience, for children with acute abdominal pain, accompanied by symptoms such as vomiting, and fever, and obvious signs of peritoneal irritation, a detailed medical history should be inquired to confirm whether there is a history of chronic abdominal pain, medication history, or other comorbidities. For those considering perforation of digestive tract ulcers, routine abdominal X-ray plain films should be performed, and attention should be paid to the gas release downstream of the diaphragm. If the ultrasound doctor's examination level is mature, they can focus on the condition of the duodenum and search for the location and diameter of the perforation. Abdominal CT plain scan can examine patients with complex perforation. When patient's vital signs are confirmed as stable, and the perforation site is located on the anterior wall of the duodenal bulb with a diameter less than 5mm or even within 1cm, conservative treatment can be taken. Patients should be treated with fasting and gastrointestinal decompression. Powerful antibiotics needs to be applied, and our center routinely uses a combination of " Cefoperazone Sodium and Sulbactam Sodium " and "Metronidazole" regimen. PPI uses omeprazole. Disease recovery requires sufficient energy support, so TPN is necessary. For somatostatin, we prefer to use continuous and micro intravenous infusion of octreotide. Reducing pancreatic secretion also helps prevent pancreatic enzymes from stimulating the perforation. During this period, patients’ blood routine, symptoms and signs need to be monitored. If the WBC count and CRP level indicators in the blood routine decrease and symptoms alleviate, it indicates that conservative treatment is effective and can continue. If the condition progresses and sepsis occurs, prompt emergency surgical treatment is required. The retention time for gastrointestinal decompression must be sufficient. By draining gastric juice, it can reduce irritation to perforation or reduce leakage from the perforation site. After the drainage flow is reduced and converted to normal transparent gastric juice, the nasogastric tube can be removed. Color ultrasound or gastrointestinal imaging can be reviewed to check the healing of the perforation. Initially, patients can drink water, and their abdominal signs need to be observed to ensure that there are no discomfort before resuming a fluid diet. After the final blood routine check indicating normal condition, antibiotics can be stopped, and patient can be discharged smoothly. PPI must continue to be taken after discharge. If the family's economic conditions permit, it is recommended to improve endoscopic examination or C-13 breath test to clarify the situation of ulcers and HP infection, and patients can undergo radical treatment to prevent the recurrence of digestive tract perforation. Our research is limited. The experience of conservative treatment is gradually summarized from the successful treatment of the first patient. However, the number of cases in this center is small and not representative. We hope that more conservative treatment cases from other centers can be reported, and we believe that the significance of conservative treatment of the duodenum in children is positive. Not all regions have experienced surgeons and advanced laparoscopic instruments, and the demand for medication seems to be more easily met. Whether it is due to gastrointestinal ulcers, medication, or trauma, timely conservative treatment for duodenal perforation in children can help reduce mortality and control disease progression. Conclusion Duodenal perforation in children is rare and often caused by primary ulcers. Most cases have a history of chronic abdominal pain, with symptoms of abdominal pain, vomiting, fever, and signs of peritonitis during acute attacks. Abdominal X-ray, abdominal CT plain scan, and color Doppler ultrasound can assist in diagnosis. As long as there is no progression to sepsis, the same treatment effect as surgical treatment with satisfactory outcomes and acceptable hospital stay can be achieved through complete conservative treatment. Abbreviations HP Helicobacter Pylori NSAIDs Non-steroidal anti-inflammatory drugs CT Computed Tomography PPI Proton Pump Inhibitor WBC White blood cell CRP C-reactive protein TPN Total parenteral nutrition WSES The World Society of Emergency Surgeons Declarations Acknowledgements The authors thank the entire staff of the Pediatric Surgery Department of Fujian Children's Hospital. Funding Not involving funds. Author Contributions Xiang Wang and Mingkun Liu conceived and designed the study, Xiang Wang wrote the manuscript .Weijun Zheng and Fei Chen collected the data. Dianming Wu,Yifan Fang and Mingkun Liu critically revised the manuscript and all authors approved the final manuscript. Conflicts of Interest The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Ethics Approval and Consent to Participate All procedures performed in studies involving human participants were in accordance with the ethical standards of the Fujian Children’s Hospital and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Written informed consent was obtained from all patients or guardians enrolled in this study. References Robb JD, Thomas PS, Orszulok J, Odling-Smee GW. Duodenal ulcer in children. Arch Dis Child. 1972 Oct;47(255):688-96. doi: 10.1136/adc.47.255.688. PMID: 5086503; PMCID: PMC1648201. Hua MC, Kong MS, Lai MW, Luo CC. Perforated peptic ulcer in children: a 20-year experience. J Pediatr Gastroenterol Nutr. 2007 Jul;45(1):71-4. doi: 10.1097/MPG.0b013e31804069cc. PMID: 17592367. Abu-Freha N, Gat R, Philip A, et al. 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Glob Pediatr Health. 2023 Mar 25;10:2333794X231156057. doi: 10.1177/2333794X231156057. PMID: 36992845; PMCID: PMC10041607. Hoshi Reina,Uehara Shuichiro,Furuya Takeshi et al. Conservative treatment for duodenal perforation after blunt trauma in a child.[J] .Pediatr Int, 2022, 64: e14965. Shen Q, Liu T, Wang S, Wang L, Wang D. Experience in diagnosis and treatment of duodenal ulcer perforation in children. BMC Pediatr. 2023 Mar 30;23(1):144. doi: 10.1186/s12887-023-03957-8. PMID: 36997985; PMCID: PMC10061964. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3894604","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Short Report","associatedPublications":[],"authors":[{"id":270675335,"identity":"3e63c7da-20de-45a2-8c20-d297d29b3f26","order_by":0,"name":"Xiang Wang","email":"","orcid":"","institution":"Fujian Children's Hospital（Fujian Branch of Shanghai Children's Medical Center）","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Xiang","middleName":"","lastName":"Wang","suffix":""},{"id":270675336,"identity":"d52650fb-3b38-44f2-b8c4-1a7fa0004c87","order_by":1,"name":"Weijun Zheng","email":"","orcid":"","institution":"Fujian Children's Hospital（Fujian Branch of Shanghai Children's Medical Center）","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Weijun","middleName":"","lastName":"Zheng","suffix":""},{"id":270675337,"identity":"ea7c608f-abc4-4d86-aa9b-e1a8bb794f29","order_by":2,"name":"Fei Chen","email":"","orcid":"","institution":"Fujian Children's Hospital（Fujian Branch of Shanghai Children's Medical Center）","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Fei","middleName":"","lastName":"Chen","suffix":""},{"id":270675338,"identity":"98541fd3-8c93-4f93-8e52-1fdecbea8096","order_by":3,"name":"Dianming Wu","email":"","orcid":"","institution":"Fujian Children's Hospital（Fujian Branch of Shanghai Children's Medical Center）","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Dianming","middleName":"","lastName":"Wu","suffix":""},{"id":270675339,"identity":"65e86c65-7e57-465d-ba0a-7729b22f4373","order_by":4,"name":"Yifan Fang","email":"","orcid":"","institution":"Fujian Children's Hospital（Fujian Branch of Shanghai Children's Medical Center）","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yifan","middleName":"","lastName":"Fang","suffix":""},{"id":270675340,"identity":"0f66396a-abe7-4bf5-adbd-2570eefd6927","order_by":5,"name":"Mingkun Liu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5klEQVRIiWNgGAWjYBACPmYgkcDAYMDAwHzggwQxWtgQWtgSZwC1ENbFBqWBWngMZzAQpYWdx3TDwx21xga3ez42WPyxqTO4kcD44WMOPofxmN1IPHPczODO2Y0Nkm1pEkAtzJIztxHS0nbMxuBG7vYHkg2HQVrYmHmJ05LzsEHiz3+itdSYAbUwNkiwHSBGC1sZUMsBY8kbaYZAvyRLzjzzsBmvX/j5D2+7+bOtzrDvRvLDZok/dvx8x5MPfviIRwsUHAaTzKBIUbiQ2EBQPRDUgUnGD0BCvv8AMTpGwSgYBaNgBAEAdMRVQIgBIp8AAAAASUVORK5CYII=","orcid":"","institution":"Fujian Children's Hospital（Fujian Branch of Shanghai Children's Medical Center）","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Mingkun","middleName":"","lastName":"Liu","suffix":""}],"badges":[],"createdAt":"2024-01-24 15:59:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3894604/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3894604/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":50684357,"identity":"aa586286-3cbc-4af8-b8dc-220ab4e5bd93","added_by":"auto","created_at":"2024-02-05 17:50:24","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":81013,"visible":true,"origin":"","legend":"\u003cp\u003eSonogram of duodenal ulcer perforation. (a) Measurement of perforation diameter and location under ultrasound. (b, c) Interruption of the anterior wall muscle layer of the duodenal bulb, gas like strong echo penetration, and edema and thickening of the duodenal wall.\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3894604/v1/0ce38ee4c0c35d1faf7b8620.jpg"},{"id":51816729,"identity":"bda92f33-e193-4f7d-bc99-f38d79646c1d","added_by":"auto","created_at":"2024-02-29 14:58:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":292059,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3894604/v1/47b1e2f6-04a6-498f-b42c-4406a58effbd.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Duodenal perforation in children: must surgery be performed?","fulltext":[{"header":"Background","content":"\u003cp\u003eDuodenal perforation is a common acute abdominal disease, but it is relatively rare in children. Due to the urgent onset and rapid progression of the disease, surgical treatment is recommended by the mainstream to reduce mortality. But does surgery really have to be done to cure it? Now we collect data on pediatric patients with duodenal perforation admitted to our center from 2022 to 2023 and share their treatment experience based on the results obtained from conservative treatment during the treatment period.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThere are a total of 6 male patients (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) with aged ranging from 8 to 14 years old. Among them, 4 cases have previous abdominal pain, lasting from 1 month to 6 months; Two patients had taken ibuprofen due to COVID-19 infection before the onset, and all patients did not take hormone drugs, alcohol and do not have other diseases. The course of the disease ranges from 4 hours to 24 hours. There were 6 cases of abdominal pain, 3 cases of vomiting, 4 cases of fever, and 1 case of black stool. All of them had signs of peritonitis. Five patients underwent abdominal CT plain scan at local hospitals, which revealed gastrointestinal perforation or subphrenic gas. After visiting our center, blood routine examination, abdominal X-ray plain film, and abdominal ultrasound were immediately improved. Only 3 cases showed subphrenic gas or pneumoperitoneum by their abdominal X-ray plain film. All patients were diagnosed with abdominal ultrasound and the location and diameter of the perforation were determined (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). There were 4 cases of anterior wall of the ball and 1 case of anterior wall at the junction of the descending part of the ball. Only one case was unable to locate and measure the diameter and was clearly explored during surgery. And all patients' amylase levels are normal.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical characteristics of patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eID\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAge(Year)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCourse of disease(h)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eClinical feature\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCT scan\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eX-ray\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003ePerforation site\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDiameter(mm)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAbdominal pain, vomiting, fever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eDigestive tract perforation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSubphrenic gas\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAnterior wall of bulb\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAbdominal pain, vomiting, fever, tarry stool\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSubphrenic gas\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePneumoperitoneum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAnterior wall of bulb\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAbdominal pain, fever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSubphrenic gas\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAnterior wall of bulb\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAbdominal pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eDigestive tract perforation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePneumoperitoneum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAnterior wall of bulb\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAbdominal pain, fever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eDigestive tract perforation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eBetween the bulb and descending part\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e6.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAbdominal pain, vomiting,shock\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAnterior wall of bulb\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eAll patients underwent fasting, nasogastric tube decompression, antibiotics, intravenous nutrition, PPI, and octreotide treatment. During this period, vital signs and changes in abdominal signs were monitored, and blood routine tests were dynamically performed.\u003c/p\u003e \u003cp\u003eAmong them, 5 patients recovered after conservative treatment. Blood routine and CRP were tested every three days, and the indicators gradually decreased and returned to normal. Gastrointestinal decompression changed from the original yellow green liquid to transparent gastric juice. After the symptoms of peritonitis were alleviated, the nasogastric tube was removed, and ultrasound examination showed that the duodenal perforation healed, restoring a fluid diet. Antibiotics should be treated with a combination of \" Cefoperazone Sodium and Sulbactam Sodium \" and \"Metronidazole\" until blood routine tests are normal. Total parenteral nutrition (TPN) support is required during fasting. Gastrointestinal decompression for 3\u0026ndash;12 days, fasting for 7\u0026ndash;13 days, and hospitalization for 10\u0026ndash;16 days.\u003c/p\u003e \u003cp\u003eOne child developed sepsis after 2 days of conservative treatment, with significantly increased signs of peritonitis and unstable vital signs. Emergency laparoscopic duodenal perforation repair was performed. During the surgery, a perforation was found on the anterior wall of the duodenal bulb, with a diameter of 5mm. After 6 days of postoperative gastrointestinal decompression and 11 days of fasting, duodenography was performed, and no contrast agent overflowed in the duodenum. The fluid quality was restored, and the abdominal drainage volume did not decrease 13 days after surgery. The chyle test was positive after taking ascites, and chyloperitoneum was considered. Follow up ultrasound showed subphrenic and pleural effusion. After treatment with fasting, PPI, octreotide and TPN, ascites gradually decreased and the hospital stay was 34 days.\u003c/p\u003e \u003cp\u003eAll patients recovered and were discharged. Continue to take omeprazole acid therapy for 8 weeks after discharge. All cases were followed up for a period of 1 month to 1 year. Only 1 patient underwent gastroscopy 3 months later, diagnosed with multiple duodenal ulcers (S2 stage), and continued treatment. The remaining 5 cases showed no signs of re perforation, bloody stools, abdominal pain, or vomiting.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOutcome of treatment in all cases\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eID\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTreatment\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFasting(d)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003edecompression(d)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHospitalization length(d)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConservative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConservative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConservative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConservative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConservative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConservative-Surgical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBlood routine and CRP change in cases with successful conservative treatment\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"16\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c14\" colnum=\"14\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c15\" colnum=\"15\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c16\" colnum=\"16\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eID\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c13\" namest=\"c11\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c16\" namest=\"c14\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWBC\u003c/p\u003e \u003cp\u003e(10\u003csup\u003e9\u003c/sup\u003e/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNE%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCRP\u003c/p\u003e \u003cp\u003e(mg/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eWBC\u003c/p\u003e \u003cp\u003e(10\u003csup\u003e9\u003c/sup\u003e/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNE%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCRP\u003c/p\u003e \u003cp\u003e(mg/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eWBC\u003c/p\u003e \u003cp\u003e(10\u003csup\u003e9\u003c/sup\u003e/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eNE%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eCRP\u003c/p\u003e \u003cp\u003e(mg/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eWBC\u003c/p\u003e \u003cp\u003e(10\u003csup\u003e9\u003c/sup\u003e/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eNE%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eCRP\u003c/p\u003e \u003cp\u003e(mg/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003eWBC\u003c/p\u003e \u003cp\u003e(10\u003csup\u003e9\u003c/sup\u003e/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003eNE%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003eCRP\u003c/p\u003e \u003cp\u003e(mg/L)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1st\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e61.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e26.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e94.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e15.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e17.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e92.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e22.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e92.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e0.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e14.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e83.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e138.19\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2nd\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e64.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e72.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e111.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e5.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e52.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e16.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e13.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e89.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e87.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e8.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e60.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e87.47\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3rd\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e63.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e49.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e4.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e42.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e7.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e7.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e69.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e30.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e11.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e69.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e37.85\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4th\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e50.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e14.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e5.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e55.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e1.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e7.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e8.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5th\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e35.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e8.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eDuodenal perforation in children is rare in clinical practice, and the number of reported cases in the literature is also relatively small \u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. A study has found that the average age of pediatric perforated peptic ulcer is 14.2 years old. 90% of them are adolescents \u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. In our study, the average age of onset of duodenal perforation in children was 11.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2.3 years old. The number of males with duodenal ulcer perforation in adults is almost three times that of females \u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. In our study, all cases were male, which is consistent with their conclusions.\u003c/p\u003e \u003cp\u003eThe main causes of duodenal perforation include trauma, iatrogenic injury, and gastrointestinal ulcer. The main causes of duodenal ulcer include Helicobacter Pylori (HP) infection, non-steroidal anti-inflammatory drugs(NSAIDs), steroid anti-inflammatory drugs, stress response, gastrinoma, etc. \u003csup\u003e[\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e. In our study, 4 children have a long history of chronic abdominal pain, of which 2 children used ibuprofen due to COVID-19 infection, and duodenal ulcer lesions were found in color ultrasound examination. Therefore, we highly suspect that these 4 children have a history of duodenal ulcer, but there is no clear history of familial HP infection. In the later follow-up, except for one child who was diagnosed with HP infection after treatment of ulcers in the digestive department, no further investigation was conducted on the status of HP infection. Based on this, a detailed inquiry about medical history, understanding past medical history and medication history, is very helpful for diagnosing the disease.\u003c/p\u003e \u003cp\u003eDue to the fact that most of our cases are older children, the description of their own symptoms is relatively clear. Their symptoms are similar to those of adults, with a history of chronic abdominal pain. After acute onset, they experience severe upper abdominal pain, vomiting, fever, and black stools. On physical examination, there are obvious signs of peritoneal irritation (abdominal tenderness, rebound pain, and abdominal muscle tension), but a few cases have severe sepsis and septic shock.\u003c/p\u003e \u003cp\u003eCurrently, the diagnosis of duodenal perforation in children is not difficult, and commonly used X-ray, abdominal CT scan, and abdominal ultrasound are the main diagnostic methods for duodenal perforation \u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. When the child has clear symptoms of perforation, they should actively improve the examination. The World Society of Emergency Surgeons (WSES) recommends that for children with suspected gastric or duodenal perforation, abdominal standing X-ray should be taken first. If the result is negative, abdominal CT plain scan should be performed to check for free gas in the abdominal cavity. If it is still negative, oral contrast enhanced CT examination is feasible for a clear diagnosis \u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e. Usually, the abdominal X-ray shows subphrenic gas in an upright position; Abdominal CT scan findings include abdominal fluid accumulation, pneumoperitoneum, and thickening of intestinal wall. However, in our study, X-ray also showed negative results. As reported in the literature, the positive rate of free gas downstream of the diaphragm on abdominal X-ray plain films of duodenal perforation is less than 40% \u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e, which may be related to the smaller diameter of the perforation and less gas entering the abdominal cavity, so negative results cannot be ruled out. Sometimes the family member of patients refuses to do CT scans because of its radiation hazards. Our patients have undergone CT scans at local hospitals to confirm gastrointestinal perforation and are referred to our center for further treatment. For all cases, we arranged experienced color Doppler ultrasound doctors for ultrasound examination, which can also diagnose duodenal perforation \u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e. Ultrasound manifestations include accumulation of gas and liquid around the duodenum, discontinuity of the duodenal wall, surrounding swelling, and abdominal fluid accumulation. Ultrasound examination not only helps us diagnose the cause, but also provides us with key information such as the location and diameter of the perforation. The most common site of digestive tract perforation in children in Europe is the duodenum, mainly located in the anterior wall \u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e. In our case, 5 cases were identified with ultrasound to determine the perforation site. 4 cases were located on the anterior wall of the ball, and 1 case was located on the anterior wall at the junction of the ball and the descending part. The diameter was less than 1cm, with 4 cases being less than 5mm and 1 case being 6.9mm. We suggest that cases with suspected duodenal perforation undergo routine ultrasound examination in order for ultrasound doctors to grasp the ultrasound manifestations of the perforation and improve the examination level. When ultrasound can diagnose perforation, abdominal CT plain scan becomes unnecessary, which can reduce the radiation harm to the child and reduce the financial burden on the family.\u003c/p\u003e \u003cp\u003eThe mainstream treatment method for duodenal perforation is active surgical intervention. Both in China and internationally, there are many literature introductions on duodenal perforation surgery \u003csup\u003e[\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e. Duodenal perforation in children is mostly single perforation and can generally be treated with repair. Laparoscopic repair of duodenal perforation has been widely carried out in patients with smaller perforation. If the perforation diameter is large, greater omentum filling repair surgery is feasible \u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. The effect of the surgery is also quite good. For example, in our case where conservative treatment failed, emergency surgical repair was performed. Although postoperative complications resulted in an extension of hospital stay, follow-up after surgery was normal.\u003c/p\u003e \u003cp\u003eDo all children with duodenal perforation require surgical treatment? The duodenal bulb is enveloped by the peritoneum, with a small perforation diameter and less leakage of intestinal contents, often limited to the peritoneum. Children have strong tissue repair ability and are prone to perforation healing. Duodenal perforation may be filled with fibrin, enveloped by omentum, or spontaneously healed by adhesion to the liver surface through the duodenum \u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e. These are the basic hypotheses for conservative treatment of duodenal perforation in children. Moreover, statistics suggest that approximately 50\u0026ndash;70% of patients with peptic ulcer perforation do not require surgery and can receive conservative treatment \u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e. The treatment guidelines in Japan indicate that conservative treatment can be adopted for cases that develop within 24 hours, have stable conditions, and have limited peritoneal irritation. A review of duodenal perforation suggests that conservative treatment is feasible for patients with stable vital signs of perforation. If sepsis or shock occurs, emergency surgery is required. And it summarized the conservative treatment measures: fasting, intravenous infusion therapy, broad-spectrum antibiotics, intravenous PPI, indwelling nasogastric tubes, eradicating Helicobacter pylori, as well as the controversial use of somatostatin \u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. In addition, some literature on the conservative treatment of postoperative duodenal perforation in children also confirme the safety and feasibility of conservative treatment \u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe onset time of the cases in this study was within 24 hours. Although the symptoms and signs were obvious, their consciousness was clear and their vital signs were stable. Ultrasound found that the perforation was single, mostly located in the anterior wall of the bulb, and the diameter of the perforation was small. Therefore, conservative treatment was adopted. The 5 cases with successful conservative treatment had fasting time of 10.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.55 days, gastrointestinal decompression time of 6.2\u0026thinsp;\u0026plusmn;\u0026thinsp;3.56 days, and total hospitalization time of 13.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.83 days. Shen reported that 32 children with duodenal perforation underwent conservative treatment, fasting for 10.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2.78 days, and a total hospital stay of 14.8\u0026thinsp;\u0026plusmn;\u0026thinsp;4.60 days \u003csup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e. It can be seen that the recovery time of conservative treatment is similar.\u003c/p\u003e \u003cp\u003eTo summarize our experience, for children with acute abdominal pain, accompanied by symptoms such as vomiting, and fever, and obvious signs of peritoneal irritation, a detailed medical history should be inquired to confirm whether there is a history of chronic abdominal pain, medication history, or other comorbidities. For those considering perforation of digestive tract ulcers, routine abdominal X-ray plain films should be performed, and attention should be paid to the gas release downstream of the diaphragm. If the ultrasound doctor's examination level is mature, they can focus on the condition of the duodenum and search for the location and diameter of the perforation. Abdominal CT plain scan can examine patients with complex perforation. When patient's vital signs are confirmed as stable, and the perforation site is located on the anterior wall of the duodenal bulb with a diameter less than 5mm or even within 1cm, conservative treatment can be taken. Patients should be treated with fasting and gastrointestinal decompression. Powerful antibiotics needs to be applied, and our center routinely uses a combination of \" Cefoperazone Sodium and Sulbactam Sodium \" and \"Metronidazole\" regimen. PPI uses omeprazole. Disease recovery requires sufficient energy support, so TPN is necessary. For somatostatin, we prefer to use continuous and micro intravenous infusion of octreotide. Reducing pancreatic secretion also helps prevent pancreatic enzymes from stimulating the perforation. During this period, patients\u0026rsquo; blood routine, symptoms and signs need to be monitored. If the WBC count and CRP level indicators in the blood routine decrease and symptoms alleviate, it indicates that conservative treatment is effective and can continue. If the condition progresses and sepsis occurs, prompt emergency surgical treatment is required. The retention time for gastrointestinal decompression must be sufficient. By draining gastric juice, it can reduce irritation to perforation or reduce leakage from the perforation site. After the drainage flow is reduced and converted to normal transparent gastric juice, the nasogastric tube can be removed. Color ultrasound or gastrointestinal imaging can be reviewed to check the healing of the perforation. Initially, patients can drink water, and their abdominal signs need to be observed to ensure that there are no discomfort before resuming a fluid diet. After the final blood routine check indicating normal condition, antibiotics can be stopped, and patient can be discharged smoothly. PPI must continue to be taken after discharge. If the family's economic conditions permit, it is recommended to improve endoscopic examination or C-13 breath test to clarify the situation of ulcers and HP infection, and patients can undergo radical treatment to prevent the recurrence of digestive tract perforation.\u003c/p\u003e \u003cp\u003eOur research is limited. The experience of conservative treatment is gradually summarized from the successful treatment of the first patient. However, the number of cases in this center is small and not representative. We hope that more conservative treatment cases from other centers can be reported, and we believe that the significance of conservative treatment of the duodenum in children is positive. Not all regions have experienced surgeons and advanced laparoscopic instruments, and the demand for medication seems to be more easily met. Whether it is due to gastrointestinal ulcers, medication, or trauma, timely conservative treatment for duodenal perforation in children can help reduce mortality and control disease progression.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eDuodenal perforation in children is rare and often caused by primary ulcers. Most cases have a history of chronic abdominal pain, with symptoms of abdominal pain, vomiting, fever, and signs of peritonitis during acute attacks. Abdominal X-ray, abdominal CT plain scan, and color Doppler ultrasound can assist in diagnosis. As long as there is no progression to sepsis, the same treatment effect as surgical treatment with satisfactory outcomes and acceptable hospital stay can be achieved through complete conservative treatment.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eHP Helicobacter Pylori\u003c/p\u003e\n\u003cp\u003eNSAIDs Non-steroidal anti-inflammatory drugs\u003c/p\u003e\n\u003cp\u003eCT Computed Tomography\u003c/p\u003e\n\u003cp\u003ePPI Proton Pump Inhibitor\u003c/p\u003e\n\u003cp\u003eWBC White blood cell\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCRP C-reactive protein\u003c/p\u003e\n\u003cp\u003eTPN Total parenteral nutrition\u003c/p\u003e\n\u003cp\u003eWSES The World Society of Emergency Surgeons\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank the entire staff of the Pediatric Surgery Department of Fujian Children\u0026apos;s Hospital.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot involving funds.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eXiang Wang and Mingkun Liu conceived and designed the study, Xiang Wang wrote the manuscript .Weijun Zheng and Fei Chen collected the data. Dianming Wu,Yifan Fang and Mingkun Liu critically revised the manuscript and all authors approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll procedures performed in studies involving human participants were in accordance with the ethical standards of the Fujian Children\u0026rsquo;s Hospital and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Written informed consent was obtained from all patients or guardians enrolled in this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eRobb JD, Thomas PS, Orszulok J, Odling-Smee GW. Duodenal ulcer in children. Arch Dis Child. 1972 Oct;47(255):688-96. doi: 10.1136/adc.47.255.688. PMID: 5086503; PMCID: PMC1648201.\u003c/li\u003e\n\u003cli\u003eHua MC, Kong MS, Lai MW, Luo CC. Perforated peptic ulcer in children: a 20-year experience. J Pediatr Gastroenterol Nutr. 2007 Jul;45(1):71-4. doi: 10.1097/MPG.0b013e31804069cc. PMID: 17592367.\u003c/li\u003e\n\u003cli\u003eAbu-Freha N, Gat R, Philip A, et al. Indications and Findings of Upper Endoscopies in Males and Females, Are They the Same or Different? J Clin Med. 2021 Apr 11;10(8):1620. doi: 10.3390/jcm10081620. PMID: 33920408; PMCID: PMC8070302.\u003c/li\u003e\n\u003cli\u003eKamada T, Satoh K, Itoh T, et al. Evidence-based clinical practice guidelines for peptic ulcer disease 2020. J Gastroenterol. 2021 Apr;56(4):303-322. doi: 10.1007/s00535-021-01769-0. Epub 2021 Feb 23. PMID: 33620586; PMCID: PMC8005399.\u003c/li\u003e\n\u003cli\u003eSabbagh P, Javanian M, Koppolu V, Vasigala VR, Ebrahimpour S. Helicobacter pylori infection in children: an overview of diagnostic methods. Eur J Clin Microbiol Infect Dis. 2019 Jun;38(6):1035-1045. doi: 10.1007/s10096-019-03502-5. Epub 2019 Feb 7. PMID: 30734129.\u003c/li\u003e\n\u003cli\u003eRehfeld JF. Gastrin and the Moderate Hypergastrinemias. Int J Mol Sci. 2021 Jun 29;22(13):6977. doi: 10.3390/ijms22136977. PMID: 34209478; PMCID: PMC8269006.\u003c/li\u003e\n\u003cli\u003eAnsari D, Tor\u0026eacute;n W, Lindberg S, Pyrh\u0026ouml;nen HS, Andersson R. Diagnosis and management of duodenal perforations: a narrative review. Scand J Gastroenterol. 2019 Aug;54(8):939-944. doi: 10.1080/00365521.2019.1647456. Epub 2019 Jul 27. PMID: 31353983.\u003c/li\u003e\n\u003cli\u003eDi Saverio S, Bassi M, Smerieri N, et al. Diagnosis and treatment of perforated or bleeding peptic ulcers: 2013 WSES position paper. World J Emerg Surg. 2014 Aug 3;9:45. doi: 10.1186/1749-7922-9-45. PMID: 25114715; PMCID: PMC4127969.．\u003c/li\u003e\n\u003cli\u003eWong CW, Chung PH, Tam PK, Wong KK. Laparoscopic versus open operation for perforated peptic ulcer in pediatric patients: A 10-year experience. J Pediatr Surg. 2015 Dec;50(12):2038-40. doi: 10.1016/j.jpedsurg.2015.08.025. Epub 2015 Aug 28. PMID: 26386878.\u003c/li\u003e\n\u003cli\u003eTarasconi A, Coccolini F, Biffl WL, et al. Perforated and bleeding peptic ulcer: WSES guidelines. World J Emerg Surg. 2020 Jan 7;15:3. doi: 10.1186/s13017-019-0283-9. PMID: 31921329; PMCID: PMC6947898.\u003c/li\u003e\n\u003cli\u003eKalach N, Bontems P, Koletzko S, et al. Frequency and risk factors of gastric and duodenal ulcers or erosions in children: a prospective 1-month European multicenter study. Eur J Gastroenterol Hepatol. 2010 Oct;22(10):1174-81. doi: 10.1097/MEG.0b013e32833d36de. PMID: 20634700.\u003c/li\u003e\n\u003cli\u003eMunoz Abraham AS, Osei H, Martino A, Kazmi S, Saxena S, Fitzpatrick CM, Villalona GA. Incidence and Outcomes of Perforated Peptic Ulcers in Children: Analysis of the Kid\u0026apos;s Inpatient Database and Report of Two Cases Treated by Laparoscopic Omental Patch Repair. J Laparoendosc Adv Surg Tech A. 2019 Feb;29(2):248-255. doi: 10.1089/lap.2018.0186. Epub 2018 Oct 23. PMID: 30351216.\u003c/li\u003e\n\u003cli\u003eEmre Ş, Aydın E, \u0026Ouml;zcan R, Topuzlu Tekant G, Erdoğan E, Şeny\u0026uuml;z OF, Celayir S. \u0026Ccedil;ocuklarda duodenum perforasyonları: Olgu serisi [Duodenum perforations in children: case series]. Ulus Travma Acil Cerrahi Derg. 2016 Jan;22(1):109-13. Turkish. doi: 10.5505/tjtes.2016.69947. PMID: 27135089.\u003c/li\u003e\n\u003cli\u003eYan X, Kuang H, Zhu Z, Wang H, Yang J, Duan X, Bian H, Zheng N, Chen X. Gastroduodenal perforation in the pediatric population: a retrospective analysis of 20 cases. Pediatr Surg Int. 2019 Apr;35(4):473-477. doi: 10.1007/s00383-018-4420-4. Epub 2018 Nov 17. PMID: 30448888.\u003c/li\u003e\n\u003cli\u003eNguyen TH, Dang TN, Schnelldorfer T. Single-Port Laparoscopic Repair of Perforated Duodenal Ulcers. World J Surg. 2020;44(5):1425\u0026ndash;30. \u003c/li\u003e\n\u003cli\u003eDonovan AJ, Vinson TL, Maulsby GO, Gewin JR. Selective treatment of duodenal ulcer with perforation. Ann Surg. 1979 May;189(5):627-36. doi: 10.1097/00000658-197905000-00013. PMID: 443915; PMCID: PMC1397180.\u003c/li\u003e\n\u003cli\u003eSongne B, Jean F, Foulatier O, Khalil H, Scott\u0026eacute; M. Traitement non op\u0026eacute;ratoire des perforations d\u0026apos;ulc\u0026egrave;re gastroduod\u0026eacute;nal. R\u0026eacute;sultats d\u0026apos;une \u0026eacute;tude prospective [Non operative treatment for perforated peptic ulcer: results of a prospective study]. Ann Chir. 2004 Dec;129(10):578-82. French. doi: 10.1016/j.anchir.2004.06.012. PMID: 15581818.\u003c/li\u003e\n\u003cli\u003eZakarya AH, Mouna L, Loubna A, Houda O, Mounir E, Fouad E, Hicham Z. Duodenal Trauma in Children: What is the Status of Non-Operative Conservative Treatment? Glob Pediatr Health. 2023 Mar 25;10:2333794X231156057. doi: 10.1177/2333794X231156057. PMID: 36992845; PMCID: PMC10041607.\u003c/li\u003e\n\u003cli\u003eHoshi Reina,Uehara Shuichiro,Furuya Takeshi et al. Conservative treatment for duodenal perforation after blunt trauma in a child.[J] .Pediatr Int, 2022, 64: e14965.\u003c/li\u003e\n\u003cli\u003eShen Q, Liu T, Wang S, Wang L, Wang D. Experience in diagnosis and treatment of duodenal ulcer perforation in children. BMC Pediatr. 2023 Mar 30;23(1):144. doi: 10.1186/s12887-023-03957-8. PMID: 36997985; PMCID: PMC10061964.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Duodenal perforation, Children, Conservative treatment","lastPublishedDoi":"10.21203/rs.3.rs-3894604/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3894604/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective：\u003c/strong\u003eThe aim of this study is to share our experience in the conservative treatment of duodenal perforation in children.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod：\u003c/strong\u003eRetrospective collection of clinical data on 6 children with duodenal perforation treated at Fujian Children's Hospital from May 2022 to October 2023. Six cases were all males, ranging in age from 8 to 14 years old, and the onset time ranged from 4 to 24 hours. Main manifestations are abdominal pain, vomiting, fever, etc. Among them, 5 children have undergone abdominal CT examination at local hospitals, indicating gastrointestinal perforation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResult：\u003c/strong\u003eAll 6 patients were diagnosed with perforation of the anterior wall of the duodenum, of which 5 cases were confirmed by ultrasound examination to be located in the bulb, and 1 case was located at the junction of the bulb and the descending part. The perforation diameter of all cases was less than 1cm.Four of them were less than 5mm, and 1 case was 6.9mm. Abdominal X-ray plain film showed 3 cases of free gas downstream of the diaphragm. Five cases underwent conservative treatment, including fasting, gastrointestinal decompression, antibiotics, proton pump inhibitor (PPI), octreotide, and nutritional support. Blood routine monitoring showed that white blood cell (WBC) count and C-reactive protein (CRP) level gradually returned to normal. They recovered after 10-16 days of hospitalization. One case underwent emergency laparoscopic repair of duodenal perforation due to sepsis after 2 days of conservative treatment. Complications such as chyloperitoneum, pleural effusion and subphrenic effusion occurred after the surgery, and the patient recovered after 34 days of hospitalization. All patients recovered and were discharged. Continue to take omeprazole acid therapy for 8 weeks after discharge. All cases were followed up for a period of 1 month to 1 year. Only 1 patient underwent gastroscopy 3 months later and, diagnosed with multiple duodenal ulcers (S2 stage), and continued treatment. The remaining 5 cases showed no signs of second time perforation, bloody stools, abdominal pain, or vomiting.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion：\u003c/strong\u003eDuodenal perforation in children is rare and often caused by primary ulcers. Most of them has a history of chronic abdominal pain, with symptoms of abdominal pain, vomiting, fever, and signs of peritonitis during acute attacks. Abdominal X-ray, abdominal CT plain scan, and ultrasound can assist in diagnosis. As long as there is no progression to sepsis, conservative treatment can achieve the same therapeutic effect as surgical treatment, with satisfactory outcomes and acceptable hospital stay.\u003c/p\u003e","manuscriptTitle":"Duodenal perforation in children: must surgery be performed?","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-05 17:50:19","doi":"10.21203/rs.3.rs-3894604/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"87eb0aa9-84d6-43b0-8da2-ffacc9c99736","owner":[],"postedDate":"February 5th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-02-29T14:50:11+00:00","versionOfRecord":[],"versionCreatedAt":"2024-02-05 17:50:19","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3894604","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3894604","identity":"rs-3894604","version":["v1"]},"buildId":"zQwnuV7TCBrMSSSToR1PI","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}