Trauma-Associated Perforation of a Duodenal Ulcer With Concomitant Acute Appendicitis Presenting As Generalized Peritonitis: A Case Report.

A perforated duodenal ulcer is a potentially life-threatening surgical emergency that may present with generalized peritonitis and require prompt operative management. Although most cases are related to peptic ulcer disease, clinical presentation following blunt abdominal trauma can create diagnostic uncertainty, particularly when imaging findings are non-specific or suggest an alternative intra-abdominal source. We report the case of a 68-year-old man with no significant medical history who presented with progressive abdominal pain four days after a ground-level fall. Physical examination revealed generalized peritoneal irritation, while contrast-enhanced computed tomography demonstrated large-volume free intraperitoneal fluid, diffuse bowel distension, and findings suspicious for acute appendicitis, without clear preoperative localization of the gastrointestinal perforation site. Emergent exploratory laparotomy revealed approximately 2 L of gastroduodenal contents, extensive fibrinous exudate, dense interloop adhesions, and a 1 cm perforation on the anterior wall of the first portion of the duodenum. The appendix was also enlarged, erythematous, and edematous. Biopsies of the ulcer margins were obtained, followed by primary duodenal repair, appendectomy, extensive peritoneal lavage, and drain placement. The postoperative course was uncomplicated, with gradual diet advancement and discharge on postoperative day 7. Histopathology showed perforated duodenal tissue with ischemic necrosis and edema, without dysplasia or malignancy, and confirmed acute appendicitis with mucosal ulceration and hemorrhagic changes. This case highlights that, in patients with generalized peritonitis, the decision for urgent surgical exploration should be driven primarily by clinical findings and the need for timely source control, while preoperative imaging may assist diagnosis but may not always precisely localize the perforation site.