Peptic ulcer disease (PUD; gastric and duodenal ulcers) remains one of the most prevalent and costly gastrointestinal diseases [1]. The annual incidence of peptic ulcer ranges from 0.1% to 0.3% [2]. Internationally, the frequency varies among countries but there are two major precipitating factors: Helicobacter pylori infection and the consumption of non-steroidal anti-inflammatory drugs (NSAIDs). Ulcer incidence increases with age for both duodenal ulcers (DUs) and gastric ulcers (GUs) and DUs [3] emerge two decades earlier than GUs, particularly in men. Several factors predict increased risk with NSAIDs, such as H. pylori infection, advanced age, comorbidities and adjunct therapy with drugs such as corticosteroids, anticoagulants and bisphoshonates. Complications (bleeding, perforation, obstruction) can occur in patients with peptic ulcers of any etiology. Perforation occurs in about 5% to 10% of patients with active ulcer disease. Duodenal, antral and gastric body ulcers account for 60%, 20% and 20% of perforations, respectively, of peptic ulcers [4, 5]. Surgical abdominal exploration (both laparoscopic and laparotomic) is always indicated in gastroduodenal perforation. Hemodynamic instability, signs of peritonitis and free extravasation of contrast material on upper gastrointestinal tract contrast studies make the decision for operation more urgent and imperative. Successful treatment of perforated peptic ulcers with a laparoscopic approach was first reported in 1990 [6, 7]. Since then, various institutions have used this technique to treat patients with perforated peptic ulcers. Contraindications for laparoscopic repair for perforated peptic ulcers include large perforations, prior abdominal surgery, a posterior location of the perforation, and a poor general state of health.

Perforation of a peptic ulcer is a surgical emergency that still carries a risk of mortality. We successfully managed a rare and difficult case of simultaneous perforation of duodenal and gastric ulcers that could have been easily misdiagnosed and undertreated. Retrospectively studying our case, we can state that there is a growing experience with laparoscopic techniques for management of peptic ulcers. A Graham patch, with or without a laparoscopic vagotomy for perforated peptic ulcers is probably the most appropriate minimally invasive approach when in experienced hands [8, 9]. Nevertheless, this case raises doubts as to the extent laparoscopy would have been a safe procedure in our case in terms of revealing both lesions.

Finally, every surgeon should strictly follow one of the basic principles of abdominal surgery and perform a thorough examination of the peritoneal cavity in every case of diffuse peritonitis, even if the underlying pathology appears to be obvious.

In summary, emergency physicians and surgeons should maintain a high level of clinical suspicion as a second perforative peptic lesion, though a rare possibility, could exist and could potentially be lethal.

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.