An unusual case of duodenal perforation caused by a blister pack: A case report and literature review

• Unnoticed ingestion of blister packs cause gastrointestinal perforation.
• Preoperative diagnosis of foreign body ingestion is often difficult.
• Duodenal perforation caused by blister packs is extremely rare.
• Perforation in the third portion of duodenum can lead to retroperitoneal abscess.
• Despite prompt management, duodenal perforation may be potentially fatal.

IntroductionIngestion of foreign bodies is a relatively common clinical problem. Blister packs have been known to be a causative agent of gastrointestinal perforation. We report a rare case of duodenal perforation caused by a blister pack, which was complicated by retroperitoneal abscess and having a poor outcome.Presentation of caseA 72 year-old man with a history of dementia presented to the emergency department with a 2-day history of backache. Upon radiological findings, perforated peptic ulcer was suspected. However, emergency laparotomy revealed a blister pack protruding from the posterior wall of the third portion of the duodenum. It was complicated by a widespread retroperitoneal abscess. After removal of the foreign body, the perforation was treated with primary suture repair and an omental patch. However, the patient died two days after operation due to sepsis.DiscussionAccording to a literature review, the ileum is the most common site of perforation caused by blister packs. To our knowledge, duodenal perforations have not been documented to date. Curative treatment often involves emergent surgery. However, duodenal perforation in the third portion may lead to retroperitoneal abscess, which can result in severe sepsis and have a poor outcome. As there is no consensus about an ideal surgical approach, retroperitoneal abscess is one of the clinical challenges for surgeons. Even with prompt management, duodenal perforation may become fatal.ConclusionUnnoticed ingestion of blister packs can cause duodenal perforation. Although prompt management is necessary, duodenal perforation, especially in the third portion, may be potentially fatal.