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Factors affecting mortality and morbidity of peptic ulcer perforation.

BACKGROUND

The term peptic ulcer disease is used broadly to include ulcerations and erosions in the stomach and duodenum due to number of causes.

Peptic Ulcer Disease (PUD) refers to the underlying tendency to develop mucosal ulcers at sites that are exposed to peptic juice (acid and pepsin). Most commonly, ulcers occur in the duodenum and stomach, but they may also occur in the oesophagus, in the small intestine, at gastroenteric anastomoses and rarely in areas of ectopic gastric mucosa, for example in Meckel's diverticula. [1]

This illness affects nearly 10% of people in our country. It is commonly found in young people at the prime of their age and has been said to be associated with "hurry, worry and curry." The factors responsible for causing ulcers include

* Cigarette smoking.

* Use of painkiller drugs.

* Physical and mental stress.

* A diet rich in chillies, coffee, colas and rice.

However, recent research has shown that the most important factor is the presence of a spiral shaped bacteria in the stomach called Helicobacter pylori. This bacterium enters the stomach by the oral route and is usually acquired at a young age. The organism may be present in about 40% of healthy people, but transformation into disease like peptic ulcer and stomach cancer occurs only in few.

The complications of peptic ulcer include haemorrhage, perforation and pyloric stenosis. Perforation of duodenal peptic ulcer is a common surgical emergency.

There is decline in incidence of peptic ulcers and elective surgery for peptic ulcers, which is attributed to the era of H2 blockers and proton pump inhibitors, which provides symptomatic relief to patient. But the percentage of patients with perforation has not declined, probably due to increased inadvertent use of NSAIDs, corticosteroids and because of irregular use of H2 antagonist drugs.

Among abdominal emergencies, perforations of peptic ulcer are third in frequencies, acute appendicitis and acute intestinal obstruction being more common. Prompt recognition of the condition is very important and only by early diagnosis and treatment it is possible to reduce the mortality.

The treatment of perforation still continues to be controversial. Just closure of perforation may save life, but chance of recurrence of ulcer is too high and patient may not turn up for a second curative surgery.

When acute or chronic duodenal ulcer perforates into the peritoneal cavity three components require treatment, viz. the ulcer, the perforation and the resultant peritonitis. The perforation and resultant peritonitis are immediate threats to the life; the ulcer in itself is not. The therapeutic priorities thus are treatment of peritonitis and securing the closure of perforation, which may be achieved with surgical procedure. [2]

In spite of better understanding of disease, effective resuscitation and prompt surgery under modern anaesthesia techniques, there is high morbidity (36%) and mortality (6%). Hence, an attempt has been made to analyse the various factors, which are affecting the morbidity/mortality of patients with peptic ulcer perforations.

MATERIALS AND METHODS

This is a case series study of 60 cases operated for peptic ulcer perforation admitted to Chigateri General Hospital and Bapuji Hospital, attached to J. J. M. Medical College, Davangere from June 2009 to May 2011.

This study was mainly conducted to assess the risk factors affecting mortality and morbidity in peptic ulcer perforation.

Inclusion Criteria

1. Patients with peptic ulcer perforation of age > 14 years.

2. Patients with duodenal or gastric perforation of peptic ulcer origin.

3. Patients who will undergo simple closure with omental patch as a standard operative procedure.

Exclusion Criteria

1. Patients with perforation of peptic ulcer origin at jejunum, ileum adjacent to Meckel's diverticulum.

2. Patients treated with conservative management.

A detailed history of suspected patients of peptic ulcer perforation regarding age, sex, previous use of NSAIDs, smoking and other associated illnesses was taken. The diagnosis was made on clinical findings supported by investigations like plain x-ray erect abdomen. Relevant investigations were performed on the patient. Preoperatively, ASA grading of patients and time frame to surgery were assessed.

Immediate resuscitation was done with nasogastric suction, intravenous fluids, antibiotics and urine output monitoring. All patients of peptic ulcer perforation were operated as simple closure with omental patch. Gastric biopsy was done to rule out perforations due to malignancy of stomach.

Patients were followed up every day with continuous bedside monitoring of vital data in the immediate postoperative period. Due attention was paid to note the development of any complication. Suitable and appropriate treatment was instituted from time to time according to the needs of the patients.

Postoperative complications like wound infection, wound dehiscence, leak from closed perforation site, fistula, peritonitis, intra-abdominal abscess, septicaemia, respiratory infections and renal failure were assessed.

After satisfactory improvement, patients were discharged from the hospital with advice regarding diet, anti-ulcer drugs and quitting of smoking/alcohol, etc. All the patients were instructed to come for regular followup.

A detailed structured proforma was used to collect this information.

The results were discussed and compared with available published literature in the form of tables and charts. Significance is assessed at 5% level of significance. Spearman correlation and chi square were used as statistical methods.

RESULTS

The peptic ulcer perforation is one of the most common surgical emergencies, third only to acute appendicitis and road traffic accidents. From June 2009 to May 2011, a total of 60 patients with peptic ulcer perforations were studied.

The highest incidence was observed in fourth decade of life. The youngest patient was 19 years old and oldest was 85 years old.

Perforation was more common in males compared to females, the ratio being 9:1. Out of 60 cases, 54 were males.

The mean age (SD) of the patients was 44.4 (15.9) years. The mean ages (SD) were for males 44.7 (16.5) years and for females 42.3 (8.4) years.

29 (48.3%) patients had postoperative complications. Most common postoperative complication was wound infection in about 23 patients followed by renal failure in 5 patients, which was managed conservatively. Respiratory failure in 4 patients and septicaemia in 3 patients.

4 patients with respiratory failure required ventilator support in postoperative period; 3 patients improved with ventilator support and 1 patient expired due to associated septicaemia.

2 patients had bilious leak through drain in postoperative period. Patients were reexplored and leak was identified from previously closed perforation site. Both patients underwent simple omental patch closure of the perforation.

One patient had residual intra-abdominal abscess, which was managed by ultrasound-guided aspiration.

In the analysis of 60 patients, only factor, viz. age of 65 years and more (p-value < 0.001) was a statistically significant predictor of mortality.

DISCUSSION

Peptic ulcer perforation is one of the commonest surgical emergencies. Although, incidence of surgery for peptic ulcer diseases has reduced drastically with advent of [H.sub.2] receptor antagonist and proton pump inhibitors, but surgery for perforation has not changed.

CONCLUSION

Perforated peptic ulcer disease is emerging as a frequent cause of acute abdomen in South India. The perforation is common between age group of 30-50 years. It is more common in males.

The duration of perforation more than 24 hours and presence of shock on admission is associated with increased morbidity and mortality in patients with peptic ulcer perforation.

Early diagnosis and prompt management of shock and septicaemia is important for better prognosis of patients.

Patients with purulent peritoneal collection have increased morbidity and mortality.

Morbidity rate in our study is 48.3% and mortality rate is 5%.

Age more than 65 years, duration of perforation of more than 24 hours before surgery, presence of shock on admission, ASA grade and purulent peritoneal collection are factors significantly associated with fatal outcomes in patients undergoing emergency surgery for perforated peptic ulcer. Therefore, proper resuscitation from shock, improving ASA grade and decreasing delay in surgery is needed to improve overall results.

Summary

In this study, 60 cases of peptic ulcer perforation were studied during the period from June 2009 to May 2011 at Chigateri General Hospital and Bapuji Hospital, attached to J. J. M. Medical College, Davangere, admitted in all units of General Surgery.

Peptic ulcer perforation was common in the age group of 30-50 years with mean age of 44 years. Elderly patients (> 65 years) had increased morbidity (p-value 0.02) and mortality (p-value < 0.001).

Peptic ulcer perforation was common in males than females in ratio of 9:1.

Smoking (58.3%) and alcohol beverage consumption (53.3%) were commonly seen in patients with peptic ulcer perforation. But these factors were less significant in postoperative morbidity and mortality.

Regular ingestion of NSAIDs and/or steroids was not an important risk factor in causation of peptic ulcer perforation. It was also not a significant risk factor in postoperative mortality and morbidity (p-value 0.19).

Previous history of peptic ulcer disease was not an important risk factor in causation peptic ulcer perforation, as sizeable number of patients did not give positive history of dyspepsia or peptic ulcer symptoms. It was also not a significant risk factor in postoperative mortality and morbidity (p-value 0.75).

8.3% patients had associated co-morbid conditions. But these conditions did not significantly affect postoperative mortality and morbidity.

Presence of gas under the diaphragm in plain x-ray erect abdomen confirms the diagnosis, but their absence does not exclude the diagnosis. In our study, all patients had gas under the diaphragm.

Shock on admission was a strong determinant of morbidity and mortality in peptic ulcer perforation. In this study, shock on admission was a significant risk factor (p-value < 0.001) for morbidity in peptic ulcer perforation. Shock is a correctable variable that must be treated before surgery to minimise morbidity and mortality rate.

73.7% patients who underwent surgery 24 hours after the onset of symptoms developed postoperative complications, i.e. 15 times more compared to patients who underwent surgery before 24 hours. So delayed surgery (> 24 hours) is associated with increased morbidity and mortality in postoperative period.

ASA score serves as a valuable predictor of mortality and morbidity in the management of perforated peptic ulcer. Each increase in ASA status caused an increase in the morbidity risk by 2 times. In our study, mortality was 100% in patients with ASA grade IV.

Resuscitation and preoperative management of the patient were as important as the surgical procedure. The surgical management of peptic ulcer perforation was mainly by simple closure of perforation with omental patch.

Purulent peritoneal collection was a significant risk factor (p-value, < 0.001) for morbidity in PUP. All 3 expired patients had purulent peritoneal collection.

Postoperative morbidity was seen in 48.3% of patients and mortality in 5%. Most common postoperative complication was wound infection (59%) followed by renal failure (13%) and septicaemia (8%).

Risk factors for morbidity and mortality in perforated peptic ulcer were aged 65 years and more, duration of perforation more than 24 hours before surgery, presence of shock on admission, higher ASA grade and purulent peritoneal collection.

REFERENCES

[1] Jordan PH. Duodenal ulcers and their surgical treatment: where did they come from? Am J Surg 1985;149(1):2-14.

[2] Johnson AG. Peptic ulcer-stomach and duodenum. In: Morris PJ, Wood WC. Oxford textbook of surgery. 2nd edn. Oxford: Oxford University Press 2000:p 997.

[3] Boey J, Choi SK, Poon A, et al. Risk stratification in perforated duodenal ulcers. A prospective validation of predictive factors. Ann Surg 1987;205(1):22-6.

[4] Irvin TT. Mortality and perforated peptic ulcer: a case for risk stratification in elderly patients. Br J Surg 1989;76(3):215-8.

[5] Wakayama T, Ishizaki Y, Mitsusada M, et al. Risk factors influencing the short term results of gastroduodenal perforation. Surg Today 1994;24(8):681-7.

[6] Noguiera C, Silva AS, Santos JN, et al. Perforated peptic ulcer: main factors of morbidity and mortality. World J Surg 2003;27(7):782-7.

[7] Testini M, Portincasa P, Piccinni G, et al. Significant factors associated with fatal outcome in emergency open surgery for perforated peptic ulcer. World J Gastroenterol 2003;9(10):2338-40.

[8] Sharma SS, Mamtani MR, Sharma MS, et al. A prospective cohort study of postoperative complications in the management of perforated peptic ulcer. BMC Surg 2006;6:8.

[9] Kocer B, Surmeli S, Solak C, et al. Factors affecting mortality and morbidity in patients with peptic ulcer perforation. J Gastroenterol Hepatol 2007;22(4):565-70.

[10] Dakubo JC, Naaeder SB, Clegg-Lamptey JN. Gastroduodenal peptic ulcer perforation. East Afr Med J 2009;86(3):100-9.

Sudhir Suresh Bhat (1), Avinash Patil (2)

(1) General Surgeon, Department of General Surgery, J. J. M. Medical College, Davangere.

(2) General Surgeon, Department of General Surgery, J. J. M. Medical College, Davangere.

Financial or Other, Competing Interest: None.

Submission 21-04-2017, Peer Review 18-05-2017, Acceptance 24-05-2017, Published 29-05-2017.

Corresponding Author:

Dr. Sudhir Suresh Bhat, HN. 2090/B, Koregalli, Shahapur, Belgaum-590003, Karnataka.

E-mail: drsudhirbhat@gmail.com

DOI: 10.14260/jemds/2017/734
Table 1. The Age and Sex Incidence in Patients with Peptic
Ulcer Perforation

Age and Sex

Age               Males                 Females
(Y ears)           No.          %         No.          %

15-19               1          1.9         0          0.0
20-29              10         18.5         0          0.0
30-39              11         20.4         2         33.3
40-49              10         18.5         2         33.3
50-59               9         16.7         2         33.3
60-69               9         16.7         0          0.0
70-79               2          3.7         0          0.0
80-89               2          3.7         0          0.0
Total              54         100.0        6         100.0
Mean  SD   44.7  16.5           42.3  8.4

Age               Total
(Y ears)           No.          %

15-19               1          1.7
20-29              10         16.7
30-39              13         21.7
40-49              12         20.0
50-59              11         18.3
60-69               9         15.0
70-79               2          3.3
80-89               2          3.3
Total              60         100.0
Mean  SD   44.4  15.9

Table 2. Postoperative Complications
in Patients with PUP

Postoperative Complications

Complications             No.

Wound Infection           23
Renal Failure              5
Respiratory Failure        4
Septicaemia                3
Leak                       2
Intra-abdominal Abscess    1

Table 3. Factors affecting Morbidity and Mortality in Patients
with PUP

Parameter                                No.   Morbidity    %

Sex                         Males        54       25       46.3
                           Females        6        4       66.7
Age                       < 65 yrs.      52       22       42.3
                          [greater        8        7       87.5
                        than or equal
                         to] 65 yrs.
Drug (NSAID + Steroid)     Present        4        1       25.0
                            Absent       56       28       50.0
H/O Smoking                Present       35       20       57.1
                            Absent       25        9       36.0
H/O Alcohol                Present       32       16       50.0
                            Absent       28       13       46.4
Associated Illness         Present        5        4       80.0
                            Absent       55       25       45.5
Time of Surgery         [greatger than   22        1       4.5
                        or equal to]
                           24 hrs.
                          > 24 hrs.      38       28       73.7
Shock                      Present       26       20       76.9
                            Absent       34        9       26.5
H/O PUD                    Present        7        3       42.9
                            Absent       53       26       49.1
ASA Grade                     I           0        0       0.0
                              II         41       13       31.7
                             III         16       13       81.3
                              IV          3        3       100.0
Hb                           < 11        10        4       40.0
                             > 11        50       25       50.0
Peritoneal Collection      Bilious       33        6       18.2
                           Purulent      27       23       85.2
Site                       Duodenal      45       20       44.4
                           Gastric       15        9       60.0

Parameter               P-Value   Mortality    %    P-Value

Sex                       0.6         3       5.6    0.72
                                      0       0.0
Age                      0.02         1       1.9    0.001
                                      2       25.0

Drug (NSAID + Steroid)   0.19         0       0.0    0.77
                                      3       5.4
H/O Smoking               0.1         2       5.7     0.7
                                      1       4.0
H/O Alcohol              0.78         1       3.1    0.41
                                      2       7.1
Associated Illness       0.14         1       20.0   0.23
                                      2       3.6
Time of Surgery         < 0.001       0       0.0    0.24

                                      3       7.9
Shock                   < 0.001       2       7.7    0.39
                                      1       2.9
H/O PUD                  0.75         0       0.0    0.68
                                      3       5.7
ASA Grade               <0.001        0       0.0     --
                                      0       0.0
                                      0       0.0     --
                                      3       100.0
Hb                       0.56         0       0.0     --
                                      3       6.0
Peritoneal Collection   < 0.001       0       0.0     --
                                      3       11.1
Site                     0.29         3       6.7     --
                                      0       0.0

Table 4. Main Risk Factors and Postoperative Complications
seen in Our Study

                                         Wound       Renal
                                         Infection   Failure

Parameter                        Total   No    %     No    %
                                  No.

Age                < 65           52     17   32.7   3    5.8
              [greater than        8     6    75.0   2    25.0
              or equal to] 65
Time          [less than or       22     1    4.5    0    0.0
             equal to] 24 hrs.
                 > 24 hrs.        38     22   57.9   5    13.2
Shock             Present         26     16   61.5   5    19.2
                  Absent          34     7    20.6   0    0.0
ASA Grade           II            41     10   24.4   0    0.0
                    III           16     10   62.5   3    18.8
                    IV             3     3    100.0  2    66.7
Peritoneal        Bilious         33     6    18.2   0    0.0
Collection       Purulent         27     17   63.0   5    18.5

             Respiratory Septicaemia Leak
             Failure

Parameter    No    %     No    %     No    %

Age          2    3.8    1    1.9    2    3.8
             2    25.0   2    25.0   0    0.0

Time         0    0.0    0    0.0    0    0.0

             4    10.5   3    7.9    2    5.3
Shock        2    7.7    2    7.7    2    7.7
             2    5.9    1    2.9    0    0.0
ASA Grade    2    4.9    0    0.0    0    0.0
             1    6.3    0    0.0    2    12.5
             1    33.3   3    100.0  0    0.0
Peritoneal   0    0.0    0    0.0    0    0.0
Collection   4    14.8   3    11.1   2    7.4

             Intra-     Death
             abdominal
             abscess

Parameter    No    %    No     %

Age          1    1.9   1     1.9
             0    0.0   2    25.0

Time         0    0.0   0     0.0

             1    2.6   3     7.9
Shock        0    0.0   2     7.7
             1    2.9   1     2.9
ASA Grade    1    2.4   0     0.0
             0    0.0   0     0.0
             0    0.0   3    100.0
Peritoneal   0    0.0   0     0.0
Collection   1    3.7   3    11.1

Table 5. Mean Age of Patients with PUP in
Various Studies

Age Incidence

Study                            Mean Age

Boey et al (1987) (3)               51
Irvin (1989) (4)                    70
Wakayama et al (1994) (5)           52
Noguiera et al (2003) (6)           53
Testini et al (2003) (7)            52
Sharma et al (2006) (8)             33
Kocer et al (2007) (9)              43
J. C. Dakubo et al (2009) (10)      41
Present Study                       44

Table 6. Sex Incidence in Patients
with PUP in Various Studies

Sex Incidence

Study                            Male : Female Ratio

R. B. Satwakar et al (1978)              9:1
J. Boey et al (1982) (3)               6.6 : 1
Noguiera et al (2003) (6)               2.5:1
Testini et al (2003) (7)                2.9:1
Sharma et al (2006) (8)                18.2:1
Kocer et al (2007) (9)                   8:1
J. C. Dakubo et al (2009) (10)          4.5:1
Present Study                            9:1

Table 7. History of use of NSAIDs, Smoking and Alcohol
Consumption in Patients with PUP in Various Studies

Parameter                 Kocer et     J. C. Dakubo   Present
                          al (2007)    et al (2009)   Series

                          No.   %      No.   %      No.   %

Drug (NSAID +   Present   24    8.9    92    36.2   4     6.7
  Steroid)      Absent    245   91.1   162   63.8   56    93.3
H/O Smoking     Present   197   73.2   32    12.6   35    58.3
                Absent    72    26.8   222   87.4   25    41.7
H/O Alcohol     Present   33    12.3   124   48.8   32    53.3
                Absent    236   87.7   130   51.2   28    46.7

Table 8. Morbidity and Mortality in Different Age Groups, Time of
Surgery and Shock

Study                 Parameter            Age of Patients

                                           < 65 Yrs.     [greater
                                                       than or equal
                                                        to] 65 Yrs.

Kocer et al        No. of Patients            216           53
  (2007) (9)          Morbidity      No.      35            30
                                      %      16.2          56.6
                      Mortality      No.       3            20
                                      %       1.4          37.7
J. C. Dakubo et    No. of Patients            220           34
  al (2009) (10)      Morbidity      No.      55             7
                                      %      25.0          20.6
                      Mortality      No.      15             9
                                      %       6.8          26.5
Present Study      No. of Patients            52             8
                      Morbidity      No.      22             7
                                      %      42.3          87.5
                      Mortality      No.       1             2
                                      %       1.9          25.0

Study              Time of Sx              Shock

                   < 24 Hrs.   > 24 Hrs.   Present   Absent

Kocer et al           189         80         16       253
  (2007) (9)          30          35         15        50
                     15.9        43.8       93.8      19.8
                       7          16         11        12
                      3.9        20.0       68.8      4.7
J. C. Dakubo et       118         136        34       220
  al (2009) (10)      17          45         13        39
                     14.4        33.1       38.2      17.7
                       8          16          7        14
                      6.8        11.8       20.6      6.4
Present Study         22          38         26        34
                       1          28         20        9
                      4.5        73.7       76.9      26.5
                       0           3          2        1
                       0          7.9        7.7      2.9
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Title Annotation:Original Research Article
Author:Bhat, Sudhir Suresh; Patil, Avinash
Publication:Journal of Evolution of Medical and Dental Sciences
Article Type:Report
Geographic Code:9INDI
Date:May 29, 2017
Words:3440
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