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The authors, analysing their casuistry of 56 cases of perforated peptic ulcer, treated with simple raffia, think this surgical act, although simple, has its own therapeutical meaning in conditions of emergency such as a peritonitic abdomen. A remote checking of such patients demonstrates the validity of said therapeutical behaviour.
Morbidity and mortality of perforated peptic ulcers (PPUs) have been higher when they occur in elderly patients. Seventy-three PPUs were reviewed to determine the factors accounting for the poor outcome in patients at or above 65 years old (elderly PPU). The presentation of 44 young PPUs was compared to 29 elderly PPUs. Delay in diagnosis, associated comorbid factors and shock on admission were found to be the primary factors. There was a significant difference between the two groups in terms of duration of pain before the diagnosis was made (8.2 h vs 16.4 h) (P < 0.05). The delay in diagnosis was partly due to the vague presentation, as 41.4% (11 patients) of the elderly presented with abdominal pain not localized in the epigastrium. In addition, 55.2% (16) of elderly patients did not have a history of prior ulcer disease and one-third (nine) did not have air under the diaphragm on chest X-ray. Significant comorbid factors were present in 65.5% compared to 15.9% in the younger group (P < 0.001). Shock on admission was present in six (20.7%) elderly patients, but only in one (2.3%) young patient (P < 0.05). As a result, morbidity was 89.6% in the elderly group compared to 27.2% in the younger patients (P < 0.001). Wound complications accounted for a significant proportion of the morbidity. Mortality was 17.2% and 2.3% respectively (P < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)
A review of 109 patients with perforated peptic ulcer revealed a sex ratio of 60:49, male:female, with mean age of 67 (76 patients greater than or equal to age 50). Peritoneal cultures were positive in 52 per cent, with the most common organisms streptococci and fungi. Subsequent infectious morbidity with these organisms was rare. Postoperative respiratory and renal failure were associated with intraoperative hypotension (systolic pressure less than 90 mm Hg). Mortality was associated with age greater than 55 and intraoperative hypotension. We conclude that in the 1980s perforated peptic ulcer occurs most frequently in older patients and that acid stomach contents does not ensure sterility, yet subsequent infectious morbidity is rare. Intraoperative hypotension, which occurs especially in patients greater than 55 years, results in significant morbidity and mortality. Attention to preoperative and intraoperative resuscitation is the single most effective therapy for reducing morbidity and mortality from this disease.
STUDY OBJECTIVE: Contribution to evaluation of the place of laparoscopic surgery in the treatment of perforated peptic ulcer. PATIENTS AND METHODS: Between January 1992 and November 1997. 17 consecutive patients underwent laparoscopic suture of a perforated peptic ulcer, with or without omentoplasty. RESULTS: Treatment was performed entirely by laparoscopy in 13 cases (76%). The median operating time was 105 min (50-220 min). The median number of doses of analgesia administered to each patient was 8 (3-20 doses). The medium hospital stay was 6 days (2-23 days). Two patients (12%) died. In 11 cases, gastroscopy was performed between 1 and 4 months after the operation, revealing healing of the ulcer in 10 cases and persistence of the ulcer in one case. None of the patients were readmitted to hospital for ulcer complications, with a median follow-up of 35 months (1-63 months). CONCLUSION: The laparoscopic treatment of perforated duodenal is a technically simple and effective procedure, intermediate between conventional surgical treatment and Taylor's method. Laparoscopic surgery may therefore have a real place in the treatment of perforated peptic ulcer.
To compare the genomic variation of Helicobacter pylori in samples obtained from patients with perforated peptic ulcer, living in the same area of Estonia but belonging to different nationalities, 50 non-consecutive patients (32 Estonians and 18 Russians) admitted in the Tartu University Hospital in 1997-1999 were studied. Gastric samples of antral mucosa were obtained during operation and analysed histologically and with PCR for detection of different genotypes of H. pylori (cagA and vacA s and m subtypes). Among the 50 perforated peptic ulcer patients with histologically proven H. pylori colonisation no sample of gastric mucosa showed the s1b subtype of the vacA gene. The perforated peptic ulcer patients were mainly infected with cagA (82%) and s1 (98%) genotypes of H. pylori. The distribution of s1a/m1, s1a/m2 and s2/m2 subtypes of vacA genes was statistically different in Estonian and Russian patients (P<0.05). In conclusion differences in the distribution of vacA s and m subtypes of H. pylori were revealed between Estonian and Russian patients with perforated peptic ulcer from Southern Estonia.
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Duodenopleural fistula is a very uncommon complication of peptic ulcer perforation and usually follows empyema after a subdiaphragmatic abscess rupture. We present a rare case of duodenopleural fistula following subdiaphragmatic abscess, which resulted in thoracic empyema after gastric perforation.
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Direct comparisons of ulcer perforation rates and trends between countries have not been made in the past. Data on hospital admissions for perforated peptic ulcer during 1 January 1979 to 31 December 1985 were collected in Hong Kong (5868 perforations) and New South Wales, Australia (1669 perforations). Age and sex specific rates per 100,000 population were calculated. In Hong Kong, annual duodenal ulcer and gastric ulcer perforation rates were 13-16 and under two per 100,000 population respectively. In New South Wales, the corresponding rates were between three and four and under two per 100,000 population, respectively. The male:female ratios for duodenal ulcer perforation were consistently about 5:1 in Hong Kong and 2:1 in New South Wales, and for gastric ulcer perforation about 2:1 and 1:1, respectively. The incidence of perforation increased with age, and there was a statistically significant rise, over time, in duodenal but not gastric ulcer perforation rates in persons aged over 60 years in New South Wales; similar trends were seen in Hong Kong. Thus duodenal ulcer perforation occurs five times more commonly in Hong Kong than in New South Wales and this is largely accountable for by the higher rates of duodenal ulcer perforation in Chinese than in Australian males. Such geographical differences can best be explained by the occurrence of multiple aetiological mechanisms in ulcer perforation. Furthermore, there appears to be an increased susceptibility and an appreciable rising trend for duodenal ulcer perforation to occur in the elderly.
OBJECTIVES: Nonsteroidal anti-inflammatory drug (NSAID) use is a strong risk factor for peptic ulcer perforation, yet little is known about the outcome of this condition among NSAID users. We examined 30-day mortality after peptic ulcer perforation associated with the use of traditional NSAIDs and newer selective cyclo-oxygenase-2 (COX-2) inhibitors. METHODS: We conducted a cohort study of patients with the first hospitalization for peptic ulcer perforation, identified in discharge registries of three Danish counties between 1991 and 2003. Data on preadmission NSAID use, other ulcer-related drugs, and comorbidity were likewise from population-based registries. Mortality was ascertained from the Civil Registration System. We compared 30-day mortality in NSAID users and nonusers while adjusting for age, gender, comorbidity, previous uncomplicated peptic ulcer, and ulcer medication use. RESULTS: Of the 2,061 patients hospitalized with peptic ulcer perforation, 38% were current NSAID users. The 30-day mortality was 25% overall, and 35% among current NSAID users. Compared with never-use, the adjusted 30-day mortality rate ratios (MRRs) were 1.8 (95% CI 1.4-2.3) for current use of NSAIDs alone and 1.6 (95% CI 1.2-2.2) for current use combined with other ulcer-associated drugs. The mortality increase associated with the use of COX-2 inhibitors was similar to that of traditional NSAIDs: adjusted MRR for users of COX-2 inhibitors alone and in combination, 2.0 (1.3-3.1) and 1.4 (0.8-2.5), and for users of traditional NSAIDs alone or in combination, 1.7 (1.3-2.3) and 1.6 (1.2-2.3). CONCLUSION: Current use of NSAIDs, including COX-2 inhibitors, is associated with a poor prognosis for patients hospitalized with peptic ulcer perforation.
A series of 349 survivors of perforated peptic ulcer was followed for periods of up to 23 years. Almost nine out of every 10 patients suffered from dyspepsia during follow-up. Subsequent elective gastroduodenal surgery was required in more than a quarter of the cases. The surgery rate for gastric ulcer was more than one and a half times that for pyloroduodenal ulcer, and for females almost double that for males. The highest rate of all was for females with gastric ulcer, of whom almost one half came for surgery. One in five patients bled during follow-up. One in eight developed stenosis of the stomach of duodenum, and one in 11 perforated again. There was a significantly increased incidence of subsequent perforation and stenosis in those with an initial perforation of 5 mm or more in diameter. Gastric carcinoma occurred in less than 2% of cases and was restricted to cases of pyloroduodenal perforation. When complications occurred, the majority did so within five years. Only 15% of the 262 patients about whom complete information was available had no complications on follow-up. The indications for definitive surgery at perforation should be extended to include perforated gastric ulcer in the female, particularly if the ulcer is large.
During 23 years a total of 155 cases of verified perforated peptic ulcer were treated conservatively, according to the routine of the department, with a complication rate of 31%, and a mortality rate of 10%. Out of the 16 deaths, 4 patients were moribund at the admission, and 10 of the 12 remaining patients had a severe associated disease. Therefore, results of conservative treatment cannot be judged from results in this group. In fact, the overally mortality rate was not not higher in this material than usually reported after surgical intervention. Long-term results (mean 11 years) in 93 patients were satisfactory in 18 our of 28 patients with acute ulcer, and in 31 out of 65 patients with chronic ulcer. The reperforation rate was 9.7%.