^1,2Assistant Professor, Department of Surgery, Government Doon Medical College, Dehradun, Uttarakhand, INDIA.

Email: drpradeepsharma77@gmail.com

RESULTS

In present study period total 56 patients were studied. All were male, most common age group was 51-60 years (37.5 %) followed by 41-50 years (23.21%).

Table 1: Age wise distribution

Duration from onset of symptoms to admission was >24 hours (30.36 %) in most of patients followed by 12-24 hours (28.57%). Most commons symptoms were pain in abdomen (100%), vomiting (100%). Anaemia (37.5%), LRTI and Pulmonary complications (19.64 %), Diabetes mellitus (12.5 %) and Hypertension (10.71%) were common comorbidities noted. Associated risk factors were previous history of PUD (41.07%), Alcohol use (64.29%), Cigarette smoking (51.79%) and Use of NSAIDs (12.5%). Presence of free gas under diaphragm was noted in 83.93% patients.

Table 2: General characteristics

Intraoperatively duodenal perforation diameter was 1–5 mm (60.71 %) in most of patients followed by 6–10 mm (23.21 %). Only 1 patient had duodenal perforation diameter was > 20mm.

Table 3: Size of duodenal perforation

Common postoperative complications were wound infection (37.5 %) and pulmonary infection (21.43 %).

Table 4: Postoperative complications.

In present study mortality within 1 month was noted in 13 patients (23.21 %). Most common factors related to mortality were delayed presentation > 24 hours (61.54 %), age > 60 years (46.15 %), diabetes mellites (38.46 %), Size of perforation > 1 cm (38.46 %) and septicaemic shock (23.08 %).

Table 5: Factors related to mortality

DISCUSSION

Pathology of duodenal ulcer perforation is traditionally related to a hypersecretory acid environment, dietary factors and stress. However, the increasing incidence of the Helicobacter pylori infection, the extensive use of NSAIDs, and the increase in alcohol and smoking abuse have changed the epidemiology of this disease.⁵ Furthermore, iatrogenic duodenal perforations are becoming more common following the widespread use of endoscopic procedures, such as endoscopic retrograde cholangiopancreatography (ERCP).⁶ Most ulcers that perforate are on the anterior wall of the duodenum or stomach. The release of food and digestive enzymes into the peritoneal cavity initially causes a chemical peritonitis. Secondary bacterial peritonitis evolves later, and as with bleeding ulcers 10% of these patients will die.^7,8 The clinical presentation of gastroduodenal perforation is usually sudden onset of abdominal pain. Localized or generalized peritonitis is typical of perforated peptic ulcer, but may be present in only two-thirds of the patients.^5,9 G Bas et al. stated in their study that recognition of symptoms was significantly later in elderly patients thereby therapeutic delay increasing the mortality rate from 0–20%.¹⁰ Similar findings were noted in present study. The diagnosis is made clinically and confirmed by presence of gas under diaphragm on radiograph, but absence does not exclude the presence of perforation. When chest x-ray does not show pneumoperitoneum, or a relatively well-patient with a sealed perforation and uncertain diagnosis, a contrast enhanced computed tomography scan (CECT) of the abdomen is useful as it has a high diagnostic accuracy of 98%.¹¹ Pavan Kumar et al.,¹² studied 50 cases of duodenal ulcer perforation (DUP), abdominal pain was the most common symptom and abdominal tenderness, rigidity, obliteration of liver dullness were important signs. Larger sized perforation, late presentation to hospital, associated co-morbid medical illness and presence of preoperative shock; all have negative impact on outcome. H. pylori eradication treatment is mandatory after simple closure of the perforation to prevent recurrence. Rohit DK et al.,^{13 s}tudied 45 patients, most of were male, presented with clinical signs of peritonitis between 24-48 hours after onset of the pain. Among the patients of peptic ulcer perforation, duodenal perforation (93.3%) is more common and which is the most common cause of perforation peritonitis. Exploratory laparotomy with simple closure of perforation with omental patch was done in all cases. The most common post-operative complication was wound infection (57.5%). The overall mortality was 11.1%. In study by G Kishore Babu et al.,¹⁴ most common age group is 60–70 years. Male to female ratio of 7:1. Highest incidence occurred during the months of September and October. Common precipitating factors were smoking, alcohol, NSAIDS. Among 110 patients 12 presented in shock, with mortality of 66%. Delayed presentation > 24 hours, Size of perforation > 1 cm, peritoneal contamination > liter were associated with increased mortality. Common postop complications were wound infection, Pneumonia. Mortality is more in elderly age group that is in patients more than 60 years of age. Similar findings were noted in present study. Kumar et al. stated that ulcer perforation greater than 5 mm is an independent risk factor for releak when simple closure with omental patch alone is performed.¹⁵ Current reports advocate omental patch closure only, often laparoscopically with postoperative anti H. pylori therapy.^16,17 Several different procedures, such as a jejunal serosal patch, Roux en-Y duodenojejunostomy, pyloric exclusion, and several variations of omental plugs have been described for large duodenal defects when the defect is felt too large to perform a primary repair. World society of emergency surgery guidelines recommended tailored approach based upon the location of the ulcer for the treatment of perforated duodenal ulcers. In case of large duodenal ulcers, we suggest considering the need of resections or repair plus/minus pyloric exclusion/external bile drainage and duodenostomy only in extreme circumstances Laparoscopic approaches to closure of duodenal perforation are now being applied widely and may become gold standard in the future especially in patients with perforations less than 10 mm size presenting within the first 24 hours of onset of pain.²⁰

CONCLUSION

Perforation of the duodenum with spillage of intraluminal contents into the peritoneal cavity is a serious health concern. Delayed presentation > 24 hours, age > 60 years size of perforation > 1 cm were common factors related to mortality in duodenal ulcer perforation patients.

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