Peptic ulcer perforation various factors determining mortality and morbidity and complications

 

Sudhir Bhat^1*_, Sanjay Karpur², Sadanad Nandihalli³

 

Abstract              Background: Peptic ulcer disease (PUD) refers to the underlying tendency to develop mucosal ulcers at sites that are exposed to peptic juice (acid and pepsin). 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. This study was mainly conducted to access the risk factors affecting mortality and morbidity in peptic ulcer perforation Methods: This is a prospective study of 60 cases operated for peptic ulcer perforation admitted to Belgavi Institute of Medical Sciences Belgavi from June 2018 to May 2020. A detailed history of suspected patients of peptic ulcer perforation regarding age, sex, previous use of NSAIDs, smoking and other associated illnesses was taken. Post operative complications were assessed. Results: Peptic ulcer perforation was common in the age group of 30-50 years with mean age 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. Regular ingestion of NSAIDs and / or steroids was not an important risk factor in causation peptic ulcer perforation. Smoking (58.3%) and alcohol beverage consumption (53.3%) were commonly seen in patients with peptic ulcer perforation. Interpretation and 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 septicemia is important for better prognosis of patients.

Keywords: Peptic Ulcer Disease.

 

INTRODUCTION

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 esophagus, in the small intestine, at gastroenteric anastomoses, and, rarely, in areas of ectopic gastric mucosa, for example, in Meckel's diverticula.

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 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, corticosteriods and because of irregular use of H₂antagonist 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. In spite of better understanding of disease, effective resuscitation and prompt surgery under modern anesthesia techniques, there is high morbidity (36%) and mortality (6%). Hence, attempt has been made to analyze the various factors, which are affecting the morbidity/mortality of patients with peptic ulcer perforations.

 METHODOLOGY

This is a prospective study of 60 cases operated for peptic ulcer perforation admitted to Belgavi Institute of Medical Sciences Belgavi from June 2018 to May 2020. This study was mainly conducted to access the risk factors affecting mortality and morbidity in peptic ulcer perforation.

Inclusion criteria: Patients with peptic ulcer perforation of age > 14 years. Patients with duodenal or gastric perforation of peptic ulcer origin. Patients who will undergo simple closure with omental patch as a standard operative procedure.

Exclusion criteria: Patients with perforation of peptic ulcer origin at jejunum, ileum adjacent to Meckel’s diverticulum. Patients treated with conservative management. Patients who will undergo vagotomy with gastrojejunostomy with simple closure or partial gastrectomy or pyloroplasty. Paediatric patients of age < 14 years presenting as peptic ulcer perforation. Patients presenting as recurrent perforation or stomal ulcer perforation.

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 everyday with continuous bedside monitoring of vital data in the immediate post operative 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 follow-up. 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.

 

 

 

 

 

OBSERVATIONS AND RESULTS

The peptic ulcer perforation is one of the most common surgical emergencies, third only to acute appendicitis and road traffic accidents. From June 2018 to May 2020 a total of 60 patients with peptic ulcer perforations were studied.

 

Table 3: The age and sex incidence in patients with peptic ulcer perforation

The highest incidence was observed in fourth decade life. The youngest patient was 19 years old and oldest was 85 years old. Perforation was more common in male compared to female, the ratio being 9:1. Out of 60 cases 54 were male. 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.

Table 4: Age related morbidity and mortality in patients with PUP

 

Table 5: History of use of NSAIDs, Smoking, Alcohol, Associated illnesses and PUD affecting morbidity and mortality in patients with PUP

 In this study 4 (6.7%) patients had history of regular ingestion of NSAIDs. History of regular smoking was present in 35 (58.3%) patients, 20 patients developed postoperative complications and 2 patients expired in postoperative period.  History of regular alcohol consumption was present in 32 (53.3%) patients, 16 patients developed postoperative complications and 1 patient expired in postoperative period. A previous history of dyspepsia or peptic ulcer symptoms was present in 7 out of 60 (11.7%) patients.

 

Table 6: Time of surgery, Shock on admission, ASA Grade affecting morbidity and mortality in patients with PUP

38 (63.3%) patients underwent surgery after 24 hours of perforation, the rest were seen before 24 hours. 28 (73.7%) patients who underwent surgery after 24 hours developed postoperative complications and 3 (7.9%) patients expired. At the time of admission, shock (systolic BP less than 100) was present in 26 (43.3%) patients. 20 (76.9%) patients developed postoperative complications and 2 (7.7%) patients expired in postoperative period. Preoperative ASA (American Society of Anesthesiologists) grade was assessed for all patients with help of anesthetists, 41 (68.3%) were grade II, 16 (26.7%) were grade III, 3 (5.0%) were grade IV. Morbidity was seen in 13 (31.7%) patients with ASA grade II, 13 (81.3%) patients with ASA grade III and 3 (100.0%) patients with grade IV. Mortality was 100% in patients with ASA grade IV.

 

Table 7: Site of perforation and Type of peritoneal collection affecting morbidity and mortality in patients with PUP

45 (75.0%) patients had duodenal perforation and 15 (25.0%) patients had gastric perforation. On exploration, 33 (55.0%) patients had bilious peritoneal collection and rest had purulent collection. All patients were treated surgically by simple omental patch closure of the perforation and good peritoneal wash was given.

 

Table 8: Postoperative complications in patients with PUP

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 septicemia 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 septicemia. 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.

 

Table 9: Various factors affecting morbidity in patients with PUP

 

Table 10: Various factors affecting mortality in patients with PUP

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

Table 11: Main risk factors and postoperative complications seen in our study.

 

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 H₂ receptor antagonist and proton pump inhibitors, but surgery for perforation has not changed.

Age incidence:

Table 12: Mean age of patients with PUP in various studies

 

Table 13: Sex incidence in patients with PUP in various studies

 

Table 14: History of use of NSAIDs, Smoking and alcohol consumption in patients with PUP in various studies

 

Table 15: Morbidity and mortality in patients with PUP in different age groups

 Table 16: Morbidity depending on time of surgery and shock on admission in patients with PUP

 

Table 17: Mortality depending on time of surgery and shock on admission in patients with PUP

 

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 septicemia 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 that 65 years, duration of perforation of more than 24hours 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 2018 to May 2020 at BELAGAVI INSTITUTE OF MEDICAL SCIENCES BELGAVI admitted in all units of General Surgery. Peptic ulcer perforation was common in the age group of 30-50 years with mean age 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 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 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 minimize 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 scores serves as valuable predictors 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 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 septicemia (8%). Risk factors for morbidity and mortality in perforated peptic ulcer were age 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.

 

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