A Case of a Perforated Duodenal Ulcer in the Context of Acute Tubular Necrosis and Urosepsis

Duodenal ulcer perforation is a life-threatening complication of peptic ulcer disease (PUD), often manifesting with acute abdominal symptoms. However, PUD itself can be asymptomatic, potentially delaying diagnosis, particularly in individuals without recognized pre-existing gastrointestinal conditions. While Helicobacter pylori infection and the use of nonsteroidal anti-inflammatory drugs are well-established primary risk factors for PUD, the condition can also develop in the absence of these common triggers or due to other less apparent causes. This report details the case of an 80-year-old male with chronic kidney disease stage 3A and a recent complicated urinary tract infection (extended-spectrum beta-lactamase-producing Escherichia coli) who presented with confusion and increased urinary frequency. His initial evaluation revealed acute kidney injury (AKI) secondary to severe dehydration and metabolic acidosis, which then progressed to urosepsis and ischemic acute tubular necrosis. Unexpectedly, during his hospital admission, he developed a sudden anterior duodenal ulcer perforation. His condition was managed successfully with an emergency exploratory laparotomy and surgical repair, followed by postoperative hemodialysis, leading to a full recovery without complications from the ulcer repair. As this patient lacked typical PUD risk factors, the ulcer was likely idiopathic in origin, with its acute presentation likely exacerbated by AKI-associated uremia, metabolic acidosis, and the physiological stress of his critical illness. This case underscores the importance of recognizing stress-related risk factors for peptic ulcer formation in critically ill patients with AKI, as prophylactic measures recommended to prevent stress ulcer bleeding may also help reduce the risk of life-threatening complications such as perforation.