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Retroperitoneal perforation of a peptic ulcer of the second part of the duodenum is an extremely uncommon complication producing both diagnostic and management difficulties. The tenth recorded case of this condition--the first managed successfully by the technique of primary closure and 'duodenal diverticulization'--is reported.
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BACKGROUND: Clear patient selection criteria and indications for laparoscopic repair of perforated duodenal ulcers are still of relevance. The purpose of our paper is to describe the early outcome results after this operation and to define the risk factors influencing the genesis of postoperative morbidity. PATIENTS AND METHODS: Fifty-one patients were operated on laparoscopically between October 1996 and October 2003 for perforated peptic ulcers. Out of them, 47 patients with perforated duodenal ulcers entered the final retrospective analysis. Twenty variables were identified, including the duration of acute symptoms before the operation, shock, underlying medical illness, ulcer size, age, Boey score and the predictive value of these variables for morbidity, conversion rates and hospital stay. The univariate data analysis was originally done using the Fisher exact test, t test, Mann Whitney, ANOVA and F tests. The data was reevaluated using multifactorial analysis with logistic and linear regression tests. RESULTS: Patient's age was 32.0+/-12.4 years. Duration of perforation was 8.0+/-10.8 hours. Shock was diagnosed in one patient (2.1%). High surgical risk according to ASA (III-IV) was estimated in 2 patients (4.3%). Laparoscopic duodenography was completed in 36 patients (76.6%). The other 11 patients (23.4%) underwent a conversion to open repair. Seven patients (19.4%) had postoperative complications. Suture leakage was confirmed in 4 patients (11.1%), and other abdominal complications were observed in 3 patients (8.3%). Pneumonia and pneumothorax were diagnosed in 3 patients. Hospital stay was 7.9+/-5.8 (4-45) days. There was no mortality. Ulcer perforation size >4-10 mm is the only significant risk factor influencing the conversion rate. An increase in the suture leakage rate was most significant with delayed presentation of >or=10 hours (p<0.0001). This risk factor influences both the postoperative pneumonia rate (>or=10 hrs., p=0.026) and hospital stay (p<0.05). CONCLUSION: Size of duodenal ulcer perforation and duration of ulcer perforation symptoms were found to be risk factors influencing the rates of conversion to open repair and genesis of postoperative morbidity.
Most reports concerning the management of patients with perforated peptic ulcers suffer from inadequate documentation of the severity of illness and the operative risk of these patients. This study attempts to evaluate the prognostic value of the APACHE II scoring system in a homogeneous group of patients with perforated peptide ulcers, to assess it as a potential clinical and research tool for future studies, and to examine its usefulness in stratifying these patients according to their surgical risk. Our results confirm the prognostic value of the APACHE II scoring system, measured either retrospectively or prospectively, in patients who undergo emergency operations for perforated ulcers. When measured preoperatively, it accurately stratifies these patients to various risk groups and should therefore be used in future trials examining various treatment aspects of this condition. Our data, evaluating the results of various procedures in subgroups of patients stratified by the APACHE II, failed to support the superiority of one approach over another.
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The incidence of perforated and bleeding peptic ulcer requiring emergency surgery was studied in a defined population before and after the introduction of histamine H2-blockers. The incidence of these ulcer complications was unchanged from 1974 to 1984 with an incidence of ulcer perforation from 4 to 10/100,000 per year and of bleeding ulcer from 5 to 10/100,000, indicating that the H2-blockers have not changed the incidence of severe ulcer complications.
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Clinical differentiation between acute myocardial infarction and peptic ulcer perforation may sometimes be difficult. We report on a sixty-five year-old patient who presented at the Emergency Department with upper abdominal pain and local tenderness suggestive of acute perforation of a gastric ulcer. However, the initial electrocardiogram (ECG) showed acute inferior wall myocardial infarction. Although abdominal pain is a major symptom of acute inferior wall myocardial infarction the history of gastritis and abdominal findings on admission of our patient required further exploration. The first plain abdominal radiograph was inconspicuous, therefore we performed a gastroscopy, which showed a prepyloric gastric ulcer. The second plain abdominal radiograph revealed air in the peritoneal cavity as sign of perforation. Echocardiography, ECG and the increase of heart enzymes confirmed acute inferior wall infarction. After successful surgical treatment of the perforated ulcer the patient recovered and progressed satisfactorily at the intensive care unit. He was discharged after three weeks and remains in good health. This case shows that rapid diagnosis and good interdisciplinary therapeutic management prevented a fatal outcome of acute myocardial infarction and concomitant gastric ulcer perforation in an elderly patient.
Generalized peritonitis is a common surgical emergency in India, the 'Tropical Spectrum' of generalized peritonitis being different from the western spectrum. A total 155 cases of generalized peritonitis were surgically treated at the All India Institute of Medical Sciences between 1981 and 1987, all patients undergoing peritoneal toilet with drainage after the cause of their peritonitis had been treated. The most common cause of peritonitis was peptic ulcer perforation, with simple closure being associated with a 2 per cent mortality, while typhoid perforation was the second most common cause. The diagnosis was clinical, supported by the operative findings of a terminal ileal perforation while bacteriological, serological and histopathological confirmation was retrospective. Appendicular perforations were less common than in the west but the clinical picture was the same. Tubercular perforations were not uncommon with a previous history of subacute intestinal obstruction and evidence of tuberculosis on chest X-ray suggesting the diagnosis. Ruptured amebic liver abscess was the most common hepatobiliary cause of generalized peritonitis with drainage of the abscess producing good results. The average hospital stay was 15 days with an overall mortality of 8 per cent.
Gastric mucosa can be found in the gallbladder as a congenital heterotopia. A case of a perforated peptic ulcer in the gallbladder with concomitant hemorrhage in heterotopic gastric mucosa causing hematemesis and melena is presented.
Of 212 cases of peritonitis found in a retrospective study of geriatric inpatients, the most common causes were mesenteric infarction, malignancy, intestinal obstruction, perforated peptic ulcer, cholecystitis, diverticulitis and perforation of the urinary bladder. The diagnostic accuracy was 47%. Abdominal pain had been observed in only 55% of the cases, and guarding and/or abdominal rigidity in only 34%. Other findings such as tachycardia and fever were more common, but the specificities of these signs were low.
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