Perforated duodenal ulcer in an adolescent the bmj. Epigastric pain is the most common symptom of duodenal ulcers. Diagnosis and treatment of perforated peptic ulcer dr. Non operative management of perforated duodenal ulcers.
Duodenal ulcer occurs in the first part of the small intestine. Every year peptic ulcer disease pud affects 4 milion people around the world. Treatment and mortality of perforated peptic ulcer. By combining clinical, radiological parameters, and apache ii score, the clinical score allowed early. A total of 198 patients with perforated gastric and duodenal ulcers were enrolled in the study between 2011 and 2016. Main outcome measures morbidity, operating time, analgesic requirements, length of hospital stay, and time to return to work. However, these same symptoms are also seen in of patients with non ulcer dyspepsia. The value of parietal cell vagotomy compared to simple closure in a selective approach to perforated duodenal ulcer. Review open access diagnosis and treatment of perforated or. Ng et al reported 80% 58 of 73 case of pdu were infected. In practical terms, when the diagnosis of a perforated duodenal ulcer is established the patient is aggressively resuscitated, nasogastric suction begun, and broad spectrum antibiotic cover instituted. Ulcers generally range between 3 mm and several centimeters in diameter.
Perforated ulcers of the upper gastrointestinal tract are potentially complicated surgical emergencies. High prevalence of helicobacter pylori infection in duodenal ulcer perforations not caused by nonsteroidal antiinflammatory drugs. Mar 25, 2020 location of ulcer mortality associated with perforated gastric ulcer is twice that associated with perforated duodenal ulcer. The duodenal suture leak rate was 7% and intraabdominal abscess rate was 2%. This report aims to evaluate the rare and unusual presentation of a perforated duodenal ulcer as acute cholecystitis methods and procedures. Nutrition therapy for perforated duodenal ulcer and. The management of large perforations of duodenal ulcers. However, these same symptoms are also seen in of patients with nonulcer dyspepsia. Peptic ulcer located in the duodenum, the shortest and widest portion of the small intestine adjacent to the pylorus of the stomach. Nonoperative management for perforated peptic ulcer. Jul 11, 2014 hemorrhage occurs in 2030% gastric outlet obstruction in 5%, and perforation in 210%. These secretions overwhelms the gastroduodenal mucosa and there is colonization of the pyloric antrum by h. Diagnosis and management of perforated duodenal ulcers.
Duodenal ulcer perforations are a common surgical emergency, but literature is silent on the exact definition, incidence, management and complications of large perforations of duodenal ulcers. Peptic ulcers may present with dyspeptic or other gastrointestinal symptoms, or may be initially asymptomatic and then present with complications such as. Peptic ulcers may present with dyspeptic or other gastrointestinal symptoms, or may be initially asymptomatic and then present with complications such as hemorrhage or perforation. Normally, the lining of the stomach and small intestines can protect itself against strong stomach acids. Diagnosis and treatment of perforated or bleeding peptic. Both gastric and duodenal ulcers relate to the corrosive action of pepsin and hydrochloric acid on the mucosa of the upper gastrointestinal tract.
A perforated ulcer, is a condition where an untreated ulcer can burn through the wall of the stomach or other areas of the gastrointestinal tract, allowing digestive juices and food to leach into the abdominal cavity. Duodenal ulcer perforations are a common cause of peritonitis. The overall mortality and morbidity rate was 3 per cent and 35 per cent respectively. Laparoscopic repair of perforated duodenal ulcer series. High % of h pylori infections reported with perforated duodenal ulcers. Sep 26, 2015 perforated peptic ulcer ppu is a surgical emergency and is associated with shortterm mortality and morbidity in up to 30 and 50% of patients, respectively.
Ppu presents as an acute abdominal condition, with. Gastric ulcers account for approximately 5% of all pud but require operation much more frequently than duondenal ulcers. Jun 25, 2005 duodenal ulcer perforations are a common surgical emergency, but literature is silent on the exact definition, incidence, management and complications of large perforations of duodenal ulcers. The management of perforated gastric ulcers sciencedirect. Laparoscopic repair of perforated duodenal ulcer series of. A crater ulcer in the lining of the beginning of the small intestine duodenum. If the patient is moribund, the ulcer is best excised by grasping it with multiple allis clamps and using a. Ppu presents as an acute abdominal condition, with localized or generalized peritonitis and a high risk for developing sepsis and death. If a tension pneumoperitoneum embarrasses respiration this can be aspirated to release the pneumoperitoneum. The ulcer is known initially as a peptic ulcer before the ulcer burns through the full thickness of the stomach or. Longterm followup of bilateral truncal vagotomy and pyloroplasty for perforated duodenal ulcer.
We present two cases of a perforated duodenal ulcer following rouxeny gastric bypass and discuss the management of these patients. If nsaid users were excluded, the number rose to 58 80%. A peptic ulcer is an open sore or raw area in the lining of the stomach or intestine. Patients and methods between october 1993 and october 1997, 30 patients underwent laparoscopic graham patch repair of perforated duodenal ulcers and 16 had an open repair.
A retrospective study of a 6year period identified 61 patients. This 43 year old man presented with acute abdominal pain. Peptic ulcer disease is common with a lifetime prevalence in the general population of 510% and an incidence of 0. Protocol for diagnosis and treatment of peptic ulcer in adults. Sebastian et al 5 reported a positive radioactive carbon urea breath test, a reliable indicator of h pylori infection. With better training in minimal access surgery now available, the time has arrived for it to take its place in the surgeons repertoire. If laparotomy is undertaken and a straightforward duodenal ulcer encountered, closure with an omental patch is wellestablished as the optimal procedure. To our knowledge, perforated duodenal ulcer secondary to use of deferasirox has not been reported in past.
Ulcer formation is caused by infection with helicobacter pylori. To provide updated epidemiological data on duodenal ulcer perforation, the incidence of the disease in norfolk, united kingdom was determined. Six patients 18 per cent who did not respond to nonoperative treatment required surgical intervention. For a perforated gastric ulcer, the procedure performed depends on the patients condition. The diagnosis of a perforated duodenal ulcer in a rygp patient can be challenging, and there is variability in the surgical treatment, especially when it comes to the possible role of removing the gastric remnant. Combining both duodenal ulcers and gastric ulcers, the rate of any. Thank you for your interest in spreading the word about the bmj. Introduction peptic ulcer disease is an ulcer caused by gastric acid or pepsin. Symptoms most patients with peptic ulcer disease present with abdominal discomfort, pain or nausea.
The management of large perforations of duodenal ulcers bmc. For this reason surgeons have shown it the greatest consideration. Complications to peptic ulcer disease include perforation, bleeding and. The ulcer is known initially as a peptic ulcer before the ulcer burns. How to do laparoscopic repair of duodenal perforation. Gastroduodenal peptic ulcer perforation article pdf available in east african medical journal 863. Complications are encountered in 10%20% of these patients and 2%14% of the ulcers will perforate 2,3. Obtaining a medical history, especially for peptic ulcer disease, h pylori infection, ingestion of nonsteroidal antiinflammatory drugs nsaids, or smoking, is essential in making the correct diagnosis. The lifethreatening condition known as peritonitis may follow, where inflammation and infection spread rapidly into the abdominal cavity affecting all the major organs. Acute perforation of a duodenal ulcer is a calamity that demands prompt surgical treatment. Ng et al 4 reported that 51 70% of 73 cases of perforated duodenal ulcer were infected with h pylori.
On the coronal image middle and, magnified, right you can. More than half of the cases are female and they are usually older and. Duodenal ulcer is an uncommonly diagnosed entity in children with an incidence of 1. A peptic ulcer is a defect in the gastric or duodenal mucosa that extends through the muscularis mucosa into the deeper layers of the wall. Ulcer pain may not correlate with the presence or severity of ulceration. Request pdf perforated peptic ulcer perforated peptic ulcer is a common emergency condition worldwide, with associated mortality rates of up to 30%.
Tenyear retrospective comparative analysis of laparoscopic. See surgical treatment of perforated peptic ulcer for more information. Pdf the management of large perforations of duodenal ulcers. The sixth decision regarding perforated duodenal ulcer. Patients with perforated peptic ulcer disease usually present with a. Emergency surgery for perforated ulcer with mortality of 630% definitive ulcer surgery often deferred with shock, poorrisk patient, age 70, prolonged perforation, abscess, or generalized peritonitis. The mortality and duodenal morbidity rates have remained unchanged for the last decade. Perforated peptic ulcer ppu is relatively rare, but lifethreatening with the mortality varying from 10% to 40% 2, 46.
Management of perforated gastric and duodenal ulcers. Review open access diagnosis and treatment of perforated. To determine the management of perforated duodenal ulcer at the university hospital. Laparoscopic repair of perforted duodenal ulcer has many advantages as less.
Khelifi et al conducted a study on 160 patients with perforated duodenal ulcer and showed that laparoscopy is a safe surgical approach in cases of perforated duodenal ulcers. In a retrospective populationbased study 20012014 that evaluated longterm mortality in 234 patients who underwent surgery for perforated peptic ulcer, mortality was 15. Hypothesis laparoscopic management of perforated duodenal ulcers is safe and effective design prospective nonrandomized controlled trial setting tertiary care academic center patients and methods between october 1993 and october 1997, 30 patients underwent laparoscopic graham patch repair of perforated duodenal ulcers and 16 had an open repair. Retroperitoneal perforation of a duodenal ulcer occurred in a 51 year female. Gastric and duodenal ulcers usually cannot be differentiated based on history alone, although some findings may be suggestive. With better training in minimal access surgery now available, the time has arrived for it. Review article an overview of history, pathogenesis and.
It has not only allowed identifying the site and pathology of perforation, but also allowed closure of the perforation with better peritoneal lavage than in the open repair. Demographics of patients with perforated peptic ulcer disease. A perforated ulcer is a condition in which an untreated ulcer can burn through the wall of the stomach or other areas of the gastrointestinal tract, allowing digestive juices and food to leak into the abdominal cavity. The incidence of perforation of duodenal ulcers in young and middle aged patients appear to be falling but in contrast, there is currently a marked. Approximately 2050% of duodenal ulcer patients report a positive family history. Laparoscopic repair of duodenal perforation is a useful method for reducing hospital stay, complications and return to normal activity. Pdf laparoscopic repair for perforated duodenal ulcer. Because of its rarity, its diagnosis is usually overlooked unless it presents with complications. Laparoscopic repair for perforated duodenal ulcer was first described in 19903.
Omental patch operative procedure for duodenal ulcers that pulls the omentum fat layer in the abdomen through the perforation and fixed to the bowel to seal off the hole created by the ulcer. Medical history included nonsteroidal antiinflammatory drugs. To assess the current management and outcome of perforated duodenal peptic ulcer managed with open repair, a focused analysis was conducted, excluding gastric, traumatic and iatrogenic perforations. In literature, there is unknown association between. Complications are encountered in 10%20% of these patients and 2%14% of the ulcers will perforate 2, 3. Other factors predisposing a person to ulcers include antiinflammatory medications and cigarette smoking. A perforated ulcer is a condition in which an untreated ulcer has burned through the mucosal wall in a segment of the gastrointestinal tract e. Mar 25, 2020 obtaining a medical history, especially for peptic ulcer disease, h pylori infection, ingestion of nonsteroidal antiinflammatory drugs nsaids, or smoking, is essential in making the correct diagnosis.
Genetic factors play a role in the pathogenesis of ulcer disease. In a study by hsu et al, combining esomeprazole and clopidogrel. Transverse ct image on the left shows the free gas anterior to the liver yellow arrow, as well some free fluid white arrow. We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. Apr 15, 2020 a perforated duodenal ulcer occurs when an area of erosion eats right through the gut wall in that part of the digestive system leading from the stomach, known as the duodenum. The usual manifestations of a complicated duodenal ulcer are perforation and hemorrhage. Thus, combining risk factors to predict disease outcome has been. A duodenal ulcer is an ulcer of the duodenum, often associated with helicobacter pylori infection. The majority of patients with perforated duodenal ulcer can be diagnosed with conventional clinical and radiological methods, and treated according to established surgical principles. A peptic ulcer on the inside of the stomach lining is a gastric ulcer, while one on the upper part of the small intestine is a duodenal ulcer. For a perforated duodenal ulcer, this may include a highly selective vagotomy, a truncal vagotomy and pyloroplasty, or vagotomy and antrectomy. The patient was seriously ill, but recovered after laparotomy with drainage of an abscess, closure of the duodenum and.
A chest radiograph showed free gas under the diaphragm. Pdf perforated peptic ulcer ppu, despite antiulcer medication and helicobacter eradication, is still the most common indication for. This protocol may be used by general practitioners, family doctors, and nurses. Nonoperative management of perforated duodenal ulcer. Mean age was 59 range 1987 years and 33 54% were male.
Our patient is a 59 year old male who presented with a several day history of persistent right upper quadrant pain as well as. Perforated gastric ulcers have a much higher mortality rate than perforated duodenal ulcers 10. Discussion duodenum is the second most common location to be affected by diverticula, after the colon. A high incidence of dehiscence and hospital mortality 1540% has been reported with the majority of the techniques. The most discriminating symptom of pain awakening the patient from sleep between 123 a.