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PubMed2006

Diabetes and 30-day mortality from peptic ulcer bleeding and perforation: a Danish population-based cohort study.

OBJECTIVE: Diabetes may influence the outcome of complicated peptic ulcer disease, due to angiopathy, blurring of symptoms, and increased risk of sepsis. We examined whether diabetes increased 30-day mortality among Danish patients hospitalized with bleeding or perforated peptic ulcers. RESEARCH DESIGN AND METHODS: This population-based cohort study took place in the three Danish counties of North Jutland, Viborg, and Aarhus between 1991 and 2003. Patients hospitalized with a first-time diagnosis of peptic ulcer bleeding or perforation were identified using the counties' hospital discharge registries. Data on diabetes, other comorbidities, and use of ulcer-associated drugs were obtained from discharge registries and prescription databases. The Danish Civil Registry System allowed complete follow-up for mortality. The outcome under study was 30-day mortality in diabetic versus nondiabetic patients, adjusted for potential confounders. RESULTS: We identified 7,232 patients hospitalized for bleeding ulcers, of whom 731 (10.1%) had diabetes. The 30-day mortality among diabetic patients was 16.6 vs. 10.1% for other patients with bleeding ulcers. The adjusted 30-day mortality rate ratio (MRR) for diabetic patients was 1.40 (95% CI 1.15-1.70). We also identified 2,061 patients with perforated ulcers, of whom 140 (6.8%) had diabetes. The 30-day mortality among diabetic patients was 42.9 vs. 24.0% in other patients with perforated ulcers, corresponding to an adjusted 30-day MRR of 1.51 (1.15-1.98). CONCLUSIONS: Among patients with peptic ulcer bleeding and perforation, diabetes appears to be associated with substantially increased short-term mortality.

Aged↗
PubMed2006

Meckel's diverticular complications in children: is laparoscopy the order of the day?

Meckel's diverticulum (MD), a seemingly innocuous anomaly of the gastrointestinal tract, presents distinctive challenges to a clinician, as it is prone to varied complications that are frequently elusive to diagnosis with conventional diagnostic modalities. This case series illustrates the diverse presentations and advantages of laparoscopic-assisted management of Meckel's diverticular complications in children. Between October 2002 and April 2006, 36 patients (27 males and 9 females) aged 1.5 to 16 years (median 10 years) underwent laparoscopic-assisted trans-umbilical Meckel's diverticulectomy (LATUM). Sixteen (44.4%) patients presented with lower gastrointestinal bleeding (14 with painless bleed and 2 with perforated peptic ulcer in the ileum adjacent to the MD), six (16.7%) patients presented with intestinal obstruction (four due to a mesodiverticular band and one each due to intussusception and floppy giant cystic dilatation of MD causing intestinal compression) and four (11.1%) patients presented with features masquerading as appendicitis (one with Meckel's diverticulitis and perforation, one with perforated peptic ulcer adjacent to MD and two with a torted and gangrenous MD). In ten (27.8%) patients, incidental MD with a narrow base was noted at laparoscopic exploration for suspected appendicitis. All patients underwent successful LATUM along with appendicectomy in 15 (41.7%) patients. The operative duration ranged from 72 to 266 min (mean 125.9+/-48.4). There were no intra-operative complications and none required conversion to open surgery. The hospital stay was 3 to 9 days (mean 5.3+/-1.2). There were three (8.3%) cases of postoperative adhesive intestinal obstruction; two underwent successful laparoscopic adhesiolysis and one necessitated conversion to suprapubic laparotomy to release the pelvic adhesions. There were no other complications during the follow-up (median 16 months). LATUM is a safe, effective and an esthetic procedure offering timely diagnosis and cure for diverse Meckel's diverticular complications. The technique also allows palpation of the MD and avoids usage of expensive staplers.

Adolescent↗
PubMed1982

The amylase-to-creatinine clearance ratio--a non-specific response to acute illness?

It was felt that the apparent specificity of the amylase-to-creatine clearance ratio (ACCR) in several previous studies of pancreatitis might reflect a failure to utilize adequately ill control subjects. The ACCR and the renal clearances of beta 2-microglobulin (B2-m), similarly related to creatinine (BCCR) as well as the urinary concentration of albumin, were compared in 27 patients with acute pancreatitis, 8 with a perforated peptic ulcer and 7 with mild biliary colic, during the first 5 days in hospital. Acute pancreatitis was graded as mild (6), moderate (14) or severe (7), using a combination of clinical data, diagnostic peritoneal lavage and multiple criteria. Further assessment of the severity of the acute illness was obtained from measurement of C-reactive protein (C-RP). Lowest C-RP levels were found in the patients with mild pancreatitis and biliary colic, and highest levels in the patients with severe pancreatitis and perforated ulcer (P less than 0.002). Similarly, ACCR and BCCR levels were significantly lower in the two mild groups than in the two severe ones (P less than 0.01 and less than 0.002 respectively), although plasma amylase was raised only in patients with pancreatitis and plasma B2-m was similar in all groups. Electrophoresis of urine showed dense bands of tubuloprotein in patients from both severe groups. Urine albumin was higher in severe pancreatitis than in perforated ulcer (P less than 0.1), perhaps indicating a more specific glomerular lesion in pancreatitis. Thus a rise in amylase clearance appeared to be related to the severity of the acute illness, and may be a component of a non-specific tubuloproteinuria. In this study patients with a perforated peptic ulcer had increases in ACCR similar to those seen in patients with severe pancreatitis, and we are therefore doubtful whether ACCR has any role in the clinical diagnosis of pancreatic disease.

Acute Disease↗
PubMed2004

Laparoscopic and endoscopic management of perforated duodenal ulcers.

BACKGROUND: Acid peptic perforation of the duodenum remains a surgical challenge. Plication alone may be satisfactory management if the ulcer diathesis is medically controlled. Laparoscopic management for plication has been safely applied in a variety of populations. This study assessed a combination of endoscopy and laparoscopy to manage early duodenal perforation. STUDY DESIGN: Forty-two patients with early (less than 12 hours) perforation were managed by laparoscopic plication and lavage. Endoscopy identified the site of perforation and guided repair in 35 of 42. All patients were followed with Helicobacter pylori treatment and examined by endoscopy at 3 months. Forty case control patients who had open procedures for duodenal perforation were evaluated for comparison. RESULTS: Endoscopic/laparoscopic management was completely effective and compared favorably with open procedures with regard to surgical time and complications. Endoscopic snaring of omentum and pulling into the defect proved to be an effective adjunct for plication. CONCLUSIONS: Endoscopic/laparoscopic repair of perforated duodenal ulcers is a safe and effective surgical tactic if followed by treatment for Helicobacter pylori.

Adolescent↗
PubMed1986

Perforated gastric ulcers. A retrospective study of 32 patients.

During the last 6 years the authors have treated 99 patients with perforated peptic ulcers. Sixty-six patients had perforated pyloro-duodenal ulcers, while 32 patients were treated for perforated gastric ulcers, a ratio of 2:1. This article deals with the gastric ulcers treated by a surgical unit in an urban, 600-bed multidisciplinary hospital. The mean age of the patients was 58.7 years. In 71.8 per cent of the patients, the perforation was the first major manifestation of the ulcer disease. Seven patients (21.8%), all in the high-risk group according to the criteria of Boey et al. died. There was no death among the low-risk patient group. Eleven patients, all high-risk, had excision and/or biopsy of the ulcer followed by simple closure; three of these patients died (27.2%). Twenty patients, of whom seven were in the high-risk group, underwent gastrectomy; three deaths occurred (15%). The authors conclude that the underlying general health of the patient is a major determinant of the outcome following gastric ulcer perforation.

Adult↗
PubMed1992

Does advancing age modify the presentation of disease?

A group of patients who had died of either cardiac tamponade due to ruptured myocardial infarct, perforated peptic ulcer, or diverticulitis with perforation were studied to determine the effect that age has on the presentation of these three potentially fatal diseases. With advanced age, a decrease in the number of patients who had symptoms typical for the disease that was ultimately the cause of death was found. We also noted a number of patients who did not experience any symptoms, and some patients who experienced symptoms that were not typical of their disease. In many instances, the disparity between disease severity and symptoms had resulted in the disease not being diagnosed either because the patient did not seek medical advice or because the doctor was unable to make the appropriate diagnosis from the patient's symptoms.

Age Factors↗
PubMedDate not supplied

Minimal access surgery--the renaissance of gastric surgery?

Peptic ulcer surgery has been revitalized by the introduction of minimal access techniques for surgery of chronic and perforated peptic ulcer. A wide range of vagotomies, including truncal vagotomy, anterior lesser curve seromyotomy with posterior truncal vagotomy and proximal gastric vagotomy, have been performed laparoscopically. Short-term (two-24 month) follow-up of laparoscopic anterior seromyotomy with posterior truncal vagotomy cases has been promising, but long-term follow-up is required to confirm these early good results. Laparoscopic repair of perforated peptic ulcers has also been described. Initial reports of laparoscopic gastrojejunostomy and Billroth II partial gastrectomy have also appeared. These procedures are technically very demanding and are currently being performed in only a few "centers of excellence" around the world. Cost-benefit analyses of medical treatment with proton-pump inhibitors versus laparoscopic vagotomy are necessary to determine which form of treatment is more economical in the long run. Criteria for patient selection need to be defined and substantiated by audit of outcome.

Humans↗
PubMed2000

Induction of cyclooxygenase-2 in mesothelial cells in peritonitis caused by perforated ulcers--an immunohistochemical study in humans.

BACKGROUND: Increasing evidence suggests that mesothelial cells contribute to the control of inflammation in the peritoneal cavity by secreting prostaglandins. A study has shown that cyclooxygenase (COX)-2 knockout mice die partly as a result of peritonitis. AIM: To investigate the expression and location of COX in peritonitis associated with peptic ulcer perforation. METHODS: Gastric and duodenal tissues were collected intraoperatively from nine and four patients, respectively, and immunohistochemical staining for COX-1 and COX-2 was performed. RESULTS: Histologically, all patients had severe peritonitis around the perforation sites, into which many inflammatory cells and fibroblasts had infiltrated, and reactive mesothelial cells exhibited hyperplastic change. The COX-1 protein was not detected, whereas COX-2 was abundant in reactive mesothelial cells near the perforation site and disappeared away from the site. Macrophages and fibroblasts around the perforation site also revealed immunostaining for COX-2. CONCLUSIONS: Our results showed that COX-2 protein is induced in mesothelial cells, as well as in macrophages and fibroblasts, in inflamed peritoneal tissues associated with peptic ulcer perforation, suggesting involvement of COX-2 in tissue repair.

Adult↗