Occult Perforation at the Ligament of Treitz in a Patient with Cirrhosis: A Case Report and Literature Review
Bibliographic record
Abstract
Background: Small intestine perforations in adults occur usually as a result of obstruction and ischemia, hernia strangulation, or trauma. When patients are found to have small intestine perforations, the location of the defect is commonly described as the distance from the ligament of Treitz, which is the suspensory ligament of the duodenum that landmarks the duodenojejunal junction. Few cases exist in which perforations occur right at the ligament of Treitz. Here, we report a rare case of an occult small intestine perforation at the ligament of Treitz in a patient with cirrhosis. Case Presentation: A 75-year-old Caucasian male with Child-Pugh class B alcoholic cirrhosis presented to the emergency department with acute abdominal pain caused by a recurrent umbilical hernia. On physical examination, he had a moderate amount of ascites and a tender mass to the right of the umbilicus. The patient was taken to the operating room (OR) for open reduction and umbilical repair. A fat-containing hernia with a small defect was reduced and 2.5 L of clear ascites was drained. Six hours after the surgery, the patient developed abdominal pain and bilious content began to drain. With differential diagnosis of inadvertent enterotomy or duodenal ulcer perforation, he was urgently taken back to the OR. No clear perforation was found: there was no duodenal ulcer, no diverticular perforation, and no inadvertent enterotomy. An intra-operative gastroscopy was undertaken and an intra-abdominal water test was performed with air insufflation. Bubbling was observed from a 5 mm perforation at the ligament of Treitz. The location of the perforation and its distance from the hernia repair excluded the possibility of iatrogenic perforation. Conclusion: This case is a reminder to examine the ligament of Treitz when searching for a perforation and that the use of intra-operative endoscopy can be useful in diagnosing occult intestinal perforations.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.000 | 0.001 |
| Meta-epidemiology (narrow) | 0.001 | 0.001 |
| Meta-epidemiology (broad) | 0.001 | 0.001 |
| Bibliometrics | 0.006 | 0.006 |
| Science and technology studies | 0.001 | 0.001 |
| Scholarly communication | 0.002 | 0.003 |
| Open science | 0.002 | 0.001 |
| Research integrity | 0.003 | 0.001 |
| Insufficient payload (model declined to judge) | 0.002 | 0.001 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".