Umesh Ramachandra Kakade

Assistant Professor, Department of General Surgery, Bharati Hospital and Medical College, Sangli, Bharati Vidyapeeth Deemed to be University, Sangli, Maharashtra, INDIA.

Email: umeshkakade66@rediffmail.com

Table 1: Age wise distribution

Common clinical features at the time of admission were tachycardia (97.75 %), abdominal rigidity (93.26 %), abdominal tenderness (91.01 %), absence of bowel sound (79.78 %), dehydration (62.92 %), abdominal distention (59.55 %), anemia (32.58 %), fever (24.72 %), manifestations of shock (16.85 %),

Table 2: Signs and symptoms on admission

Duration from onset of symptoms to admission was 12-24 hours (31.46 %) in majority of patients. Associated risk factors noted were smoking (52.81 %), alcoholism (50.56 %), previous history of PUD (17.98 %), diabetes mellites (15.73 %), use of NSAIDs (15.73 %) and stress (12.36 %). Intra-operatively, perforation diameter was 1–5 mm in majority of cases (62.92 %) followed by 6–10 mm (20.22 %). Peritoneal contamination was < 1 litre in majority of cases (77.53 %). Major postoperative complications in present study were respiratory complication (25.84 %), paralytic ileus (19.10 %), septicaemia (16.85 %), wound infections (14.61 %), burst abdomen (5.62 %). Mortality in 6 months was noted in 13 cases (14.61 %).

Table 3: General characteristics

In present study factors significantly associated with mortality were age > 60 years, septicemic shock on admission, size of perforation > 1 cm, delayed presentation > 24 hours, smoking, diabetes mellites and peritoneal contamination > 2 litre.

Table 4: Factors related to mortality

DISCUSSION

Perforated peptic ulcer allows entry of gastric and duodenal contents into the peritoneal cavity resulting in chemical peritonitis and further bacterial contamination which leads to suppurative peritonitis. 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 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%.⁶ 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%.⁷ H. pylori infection can be held responsible in more than 90% of duodenal ulcers and in up to 80% of gastric ulcers.⁸ H. pylori infection and the accompanying inflammation disrupts the inhibitory control of gastrin release by decreasing antral somatostatin, and this is more marked if the infecting organism is a cag A-positive strain. Cigarrete smoking is also a major contributor for DU pathology. It is known that smoking inhibits pancreatic bicarbonate secretions, which tend to neutralize acid secretion, thus predisposing to increased acidity in the duodenal bulb. It also causes a delay in duodenal ulcer healing. Smoking prevalence of 84% have been reported among patients with duodenal ulcer perforation and smoker have three-fold higher mortality from peptic ulcer perforation than non-smoker.⁹ In a study by Kishore Babu,¹⁰ most common age group was 60–70 years and male to female ratio was 7:1. 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 was more in elderly age group that is in patients more than 60 years of age. Early presentation, prompt diagnosis, adequate resuscitation, emergency surgery and postoperative monitoring are useful for successful management and good outcome of perforated peptic ulcer. Similar findings were noted in present study Laishram OS¹¹ studied 110 patients, 96.3% were males and 41-50 years was the most common age group. Majority (80%) belong to laborious workers commonly associated with alcohol intake and smoking. Pain was the most consistent symptom while guarding (89.1%), tenderness (81.8%) and obliteration of liver dullness(76.4%)were the most important signs present. Gas under the diaphragm was present in 97.3% of patients. Mortality rate was 6.4%. Pre-operative shock, old age, longer duration of perforation, concurrent medical illness and higher grade of peritoneal contamination are the main factors affecting the morbidity and mortality in duodenal ulcer perforation. In study by Sharma PC,¹² all cases were male, most common age group was 51-60 years (37.5%), duration from onset of symptoms to admission was >24 hours (30.36%). 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. Intraoperatively duodenal perforation diameter was 1–5 mm (60.71%) in most of patients. Common postoperative complications were wound infection (37.5%) and pulmonary infection (21.43%). 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%). In study by Kassim Trayem¹³, of the 100 cases, 96% were males and 4% were females with mean age of 43.13 years. The disease was more common in rural areas (58%), 55 % of patients had previous history of duodenal ulcer and 45% had no previous history of duodenal ulcer. The most common risk factors are smoking (32%) and NSIADs (25%). Most patients admitted to hospital between 19–24 hours (21%), (8%) admitted during 6 hours and (2%) admitted after 120 hours. Regarding the complications occurs in this study, wound infections, chest infections and paralytic ileus were the most common complications. Mortality rate was 2%. Age ≥60 years, female gender, presence of co-morbidities, preoperative shock, higher ASA grade, perforation-surgery interval >24 hours, Purulent intraperitoneal collection are inter-related statistically significant predictors of mortality.¹⁴ Larger sized perforation, late presentation to hospital, associated co-morbid medical illness and presence of preoperative shock; all have negative impact on outcome.¹⁵ Thorough peritoneal toilet al.ong with adequate fluid and electrolyte replacement, improvement in critical care and ICCU facilities are some of the factors which have improved the prognosis of duodenal ulcer perforation. Identifying variables which influence the outcome of patients with peritonitis is an important initial step. Once these factors have been identified, the outcome of patients can be correctly predicted and better management can be instituted to those patients in need.

CONCLUSION

In present study factors significantly associated with mortality in patients with peritonitis due to duodenal ulcer perforation were age > 60 years, septicemic shock on admission, size of perforation > 1 cm, delayed presentation > 24 hours, smoking, diabetes mellites and peritoneal contamination > 2 litre.

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