in various studies , the association of hypercalcemia and peptic ulcer is well established [ 1 , 2 , 3 , 4 ] , while in others this matter is still under debate [ 5 , 6 , 7 , 8 , 9 , 10 ] . the fact is that 12% of patients with primary hyperparathyroidism have peptic ulcer - related symptoms [ 11 , 12 ] , and these symptoms can be relieved after surgical removal of the abnormal parathyroid gland(s ) because of the reported reduction of elevated basal acid output ( bao ) [ 1 , 2 , 3 , 4 ] . here , we present a rare case of perforated duodenal ulcer as the initial clinical manifestation of unknown primary hyperparathyroidism . after diagnosis of the disease and unsuccessful conservative treatment of the hypercalcemia , the patient was treated by performing an emergency parathyroidectomy due to very elevated serum calcium levels . a 48-year - old male patient was admitted to the first surgical department of the university general hospital of alexandroupolis with acute mid - epigastric abdominal pain , with sudden onset , accompanied by nausea , without vomiting . the patient had no personal history of any disease , but he reported vague symptoms of dyspepsia and nausea for 15 days . an upright chest radiograph showed pneumoperitoneum , which confirmed the clinical suspicion of a perforation in the stomach or the small intestine , while ultrasonography showed intra - abdominal fluid . on routine preoperative investigation , serum calcium level was found to be elevated ( 12.9 mg / dl , normal range 8.410.2 mg / dl ) , with low phosphorus level ( 2.1 mg / dl , normal range 2.74.5 mg / dl ) . after loop diuretics ( furosemide ) administration for reducing calcium level , a laparotomy was decided , where a perforation of a duodenal ulcer was found and simple closure was performed . postoperatively , calcium level continued to rise , reaching a maximum of 14.9 mg / dl despite the administration of diuretic treatment and calcitonin . in further examinations , plasma parathyroid hormone level was found to be elevated ( 340.3 pg / ml , normal range 1565 pg / ml ) , while serum gastrin level was normal ( 99 pg / ml , normal range 5200 pg / ml ) . primary hyperparathyroidism was diagnosed and an ultrasonographic examination of the neck was performed in order to localize a possible adenoma of a parathyroid gland , the most common cause of primary hyperparathyroidism , which showed a lesion of 2.6  1.7 cm in the right anterior neck . because of the very elevated calcium level , an emergency neck exploration was performed on the 6th postoperative day ( after laparotomy ) . in surgery , the right inferior parathyroid gland was found to be hyperplastic and was removed ( fig . 1 , fig . histology of the lesion revealed a large typical parathyroid adenoma ( 3.2  2.0  1.5 cm , 6 g ) . 3 ) , while monitoring of gastric ph was also performed on the 8th postoperative day after the parathyroidectomy , finding the gastric acidity at a normal level . the patient 's postoperative course was uncomplicated and he was discharged on the 11th postoperative day after laparotomy with a pth level of 42.1 pg / ml and a calcium level of 8.8 mg / dl . the follow - up endoscopy one month after discharge showed complete healing of the duodenal ulcer and the rapid urease test proved negative for helicobacter pylori , while pth and calcium levels were 62.3 pg / ml and 9.0 mg / dl , respectively . primary hyperparathyroidism formerly presented with the  classic pentad of symptoms ( kidney stones , painful bones , abdominal groans , psychic moans and fatigue overtones ) . in the last two decades , the evolution of technology led to routine measurements of serum calcium and parathyroid hormone levels , and most patients in our time are minimally symptomatic or asymptomatic . nowadays , most symptomatic patients present with symptoms of muscle weakness ( 70% ) , myalgia - arthralgia ( 54% ) , constipation ( 32% ) , nephrolithiasis ( 30% ) , polyuria ( 28% ) , peptic ulcer disease ( 12% ) etc . [ 11 , 13 ] . in this report , the patient had no prior symptoms of primary hyperparathyroidism , and the first manifestation of the disease probably was the perforation of the peptic ulcer . this is an unusual case of asymptomatic hyperparathyroidism , considering the very elevated calcium level ( 12.9 mg / dl ) , the size of the adenoma ( 3.2  2.0  1.5 cm ) and the very elevated parathyroid hormone level ( 340.3 pg / ml ) . primary hyperparathyroidism is associated with peptic ulcer disease , although the complete pathophysiological mechanism is not established yet . in cases where primary hyperparathyroidism is included in multiple endocrine neoplasia i ( men i ) and zollinger - ellison syndrome , peptic ulcer is generated by elevated gastrin level , which results in various clinical symptoms from the gastrointestinal system . on the other hand , in cases where primary hyperparathyroidism does not coexist with elevated gastrin level , the pathophysiological mechanism is still unknown . in various studies , an increased calcium level is reported to result in an increase of gastric acid secretion and gastrin level [ 14 , 15 ] . on the other hand , several studies report that the association between hyperparathyroidism and an increased risk of peptic ulcer is controversial [ 5 , 6 , 7 , 8 , 9 , 10 ] and that chronic hypercalcemia does not affect gastric acid and gastrin secretion [ 5 , 8 , 16 , 17 ] . recently , many authors support the view that the activation of stomach calcium sensing receptor ( scar ) on the basolateral membrane of gastric parietal cells by ca leads to increased gastric acid secretion , but these results are based on acute elevation of calcium level , and further studies to support this model are necessary . in our patient , the proposed hypothesis , since rapid urease test was negative and serum gastrin level was normal , is that for unknown reasons the serum calcium level of the patient increased rapidly , a fact that led to increased gastric acid secretion through activation of scar , and all this resulted in the acute formation of duodenal ulcer and perforation . furthermore , one month after surgery , the endoscopic image of the stomach and duodenum is normal and the parathyroid hormone and calcium levels are normalized , which supports the hypothesis that the peptic ulcer was caused by hyperparathyroidism . peptic ulcer and its complications are usual manifestations of primary hyperparathyroidism , with or without increased gastrin level . on the other hand , cases of a perforation of peptic ulcer as the first clinical manifestation of primary hyperparathyroidism are extremely rare , and where possible , must be treated by a surgical team specialized in endocrine surgery , conservatively at first and surgically where needed .
a patient admitted for acute abdomen was incidentally found with elevated serum calcium level . in surgery , under conservative treatment of the hypercalcemia , a perforated duodenal ulcer was found and simple closure was performed . 
 postoperatively , calcium level continued to rise , parathyroid hormone was elevated and ultrasonographic examination showed a lesion in the right anterior neck , while serum gastrin level was normal , thus documenting the diagnosis of primary hyperparathyroidism . 
 conservative treatment had no effect on calcium level and the patient was subjected to emergency neck exploration , where a large parathyroid adenoma was removed . 
 after surgery , calcium and pth levels were normalized and the patient was discharged on the 5th postoperative day . peptic ulcer and its complications are usual manifestations of primary hyperparathyroidism , with or without increased gastrin level . 
 on the other hand , cases of a perforation of peptic ulcer as the first clinical manifestation of primary hyperparathyroidism are extremely rare .