Year : 1997 | Volume
: 3 | Issue : 2 | Page : 90--93
Perforated duodenal ulcer in Asir central hospital
Suleiman Jastaniah, Mohammad Yahia Al Naami, Tarek M.S Malatani
College of Medicine, Asir Central Hospital, King Saud University, Abha Branch, Abha, Saudi Arabia
College of Medicine, P.O. Box 641, Abha
In a study of 27 cases of perforated duodenal ulcer seen at Asir Central Hospital over a period of seven years, two patients were females and 25 males. The highest incidence was in the fourth decade and the average age was 36.3 years. The Saudi-foreigner ratio was 1:2.9 in an area where the Saudi-foreigner population ratio was 1:3. Nine patients (33.3%) were previously diagnosed as having peptic ulcer and had received treatment at one time or the other before perforation. Eighteen patients (66.7%) were first diagnosed to peptic ulcer after the perforation. All the identified perforations were located anteriorly and anterosuperiorly. Only one case occurred in the second part of duodenum. The rest occurred in the first part. Two patients were treated successfully conservatively. The month perforations occurred most was the month of Shaaban. The fasting period during the month of Ramadhan did not show any increase in the prevalence of perforation in this hospital.
|How to cite this article:|
Jastaniah S, Al Naami MY, Malatani TM. Perforated duodenal ulcer in Asir central hospital.Saudi J Gastroenterol 1997;3:90-93
|How to cite this URL:|
Jastaniah S, Al Naami MY, Malatani TM. Perforated duodenal ulcer in Asir central hospital. Saudi J Gastroenterol [serial online] 1997 [cited 2021 Jan 28 ];3:90-93
Available from: https://www.saudijgastro.com/text.asp?1997/3/2/90/33932
Since Asir Central Hospital was commissioned in 1408 H (1988) as a specialist and teaching hospital, our initial research efforts have been directed to mapping out the various patterns of diseases seen in the hospital. This is to provide a foundation for the future studies of disease processes in Asir region of Saudi Arabia, an area where very little medical reports have emanated so far.
The incidence of chronic duodenal ulcer varies in any one population from year to year  . It is also known that duodenal ulcer is a relatively common condition in many developing countries  . However. unlike many industrialized countries, in some young developing countries like Saudi Arabia, the diagnosis of duodenal ulcer in some cases is first made after perforation  .
Therefore, we decided to study the duodenal ulcer that first presented with perforation over a period of about eight years 07.03.1408 - 29.05.1416 H (1988 - 1955) in this environment.
Patients and Methods
The case notes of all the patients diagnosed as cases of perforated duodenal ulcer from the period this hospital was commissioned in 1408 H till 29.05.1416 H (1988 till September 1995) were studied. The clinical features, the location of the perforation, the treatment given and the outcome of the treatment given were noted.
The age, sex and nationality of the patients were noted. It was also observed whether the patients were diagnosed as cases of peptic ulcer before perforation, and if so, whether they were on medical treatment or not.
Findings and Results
During a seven-year period 27 cases of perforated duodenal ulcer seen at Asir Central Hospital, Abha were studied. Two patients were females and 25 males. The female-male ratio was 1:12.5.
The highest incidence was in the fourth decade, 13 cases (48.1%) followed by the third decade, six cases (22.2%). The fifth decade and over 50 years of age recorded four cases each (14.8% each). The youngest patient was 21 years and the oldest was 70 years old. Average age was 36.3 years.
Seven patients were Saudi nationals and 20 were foreigners. A Saudi-foreigner population ratio is 1:3.
Nine patients (33.3%) were previously diagnosed as having peptic ulcer prior to perforation. Many of them had received treatment for this at one time or the other. The presence of duodenal ulcer in 18 patients (66.7%) was first shown by perforation.
The patients presented between one and 48 hours. The average time of presentation from the time of the first symptom to the time when first seen was 24.9 hours.
Apart from one case in which perforation was located in the second part of duodenum, all the other cases were located in the first part of duodenum. Five cases (18.5%) were in the anterosuperior position, 20 cases (74.1%) were in the anterior position, and the locations of the perforations in the two patients (7.4%) who refused surgery were not known.
The two patients who refused surgery were managed successfully with conservative treatment. Two patients among those who had laparotomy were found to have the perforation already sealed by omentum.
Plain abdominal roentgenogram showing pneumoperitoneum was diagnostic in all the cases. Ultrasonography of the abdomen was not of much help apart from showing the presence of some fluid in the peritoneal cavity.
Eighteen patients (66.7%) had omental patch, seven patients (25.9%) had vagotomy and pyloroplasty and two patients (7.4%) were treated conservatively because they refused surgical intervention. One of those who refused surgery was a 70-year-old lady with a recent history of myocardial infarction.
The highest incidence of perforation was seen in the month of Shaaban (18.5%) and none was seen in the months of Safar and Rajab. However, there is no statistical significance to these values.
There was no direct mortality in this series although two patients died in subsequent admissions. One died of ischaemic heart disease five years after the surgery and the other died two months after the initial operation of an undetermined cause.
Even though recent studies from Scotland showed that the prophylactic use of H 2 - receptor antagonists reduces both ulcer recurrence and the risk of ulcer complications, epidemiological studies have not shown any evidence of an effect of gastric antisecretory drugs on complicated ulcer disease  .
It has been claimed that, in many young developing countries, the diagnosis of duodenal ulcer is first made in many instances after perforation  . This series confirms this because 66.7% of the patients with perforation were not diagnosed previously as cases of duodenal ulcer and therefore were not on treatment.
The use of non-steroidal anti-inflammatory drugs (NSAIDs) did seem to play significant role in the perforation is seen. Most of the patients were in the younger age group with an average age of 36.6 years. The few elderly patients in the group showed no record of wide use of NSAIDs.
Without the initial diagnosis of duodenal ulcer however, the usefulness of all the new ulcer drugs such as Cimetidine, Ranitidine, Tripotassium dicitrate Bismuthate (De Nol) and Omeprazole (Losec) ,,, in preventing perforation is questionable.
Twenty patients (74.1%) of all the cases were foreigners who came here for employment, many without their families and in a different environment. This will tend to point to the fact that stress in various forms contributed to the condition of perforated duodenal ulcer. The ratio of Saudi to non-Saudi in the area was about 1:3. However, the ratio of perforated duodenal ulcer among the Saudi to non-Saudi was 1:2.9. The foreigners were more likely to be under stress than the Saudi nationals.
The report of others that perforation is more common in males than females is confirmed in this series. However, the very low incidence here in females can be explained by the fact that life is managed mainly by men.
Since nine patients (33.3%) in this series had a previous history of treatment for duodenal ulcer, one can conclude that the patients did not comply with the treatment or that the treatment given were not effective, or both.
The classical presentation is sudden severe abdominal pain and vomiting. Examination of the abdomen often reveals classical features of peritonitis.
The diagnosis of perforated duodenal ulcer is confirmed by pneumoperitoneum on plain X-ray of the abdomen. The abdominal ultrasonography is not of much use. Pneumogastrogram has been shown to increase the diagnostic yield up to 91 percent  .
When there are contraindications to surgical procedures like a recent myocadial infarction and associated abscess, perforated duodenal ulcer can be treated successfully by conservative treatment ,, . Two patients who refused surgery in this series and two other patients seen with sealed perforations by omentum at surgery support this.
Intractable and a relapse of duodenal ulcer after initially successful medical therapy has been shown to be due in many cases to infection with Helicobacter pylori. Such has been shown to respond well to quadruple therapy: Omeprazole, Tripotassium dicitrate bismuthate (De Nol), Tetracycline and metronidazole , . Some have substituted amoxycillin for tetracycline with equally good results  .
The decision at laparotomy whether to do a simple closure or perform a definitive ulcer opertion depends on many factors. This includes the duration of perforation, the degree of soilage of the peritoneal cavity, the experience of the surgeon and the possibility of full medical treatment after surgery. The various risk factors will determine the procedure to select  .
Using omental patch to close the perforation is well accepted and various methods of this have been described , . Recently, laparoscopic repair of perforated peptic ulcer has also been reported, ,,,, and this is believed to help reduce postoperative morbidity and mortality  . We do not have personal experience with this method, but from the reports of various workers, it is probably too soon to claim any benefit over the conventional laparotomy. The mortality rate reported in perforated duodenal ulcer is between 10 and 30 percent  . However, when lesser procedures than definitive surgery is performed anti-secretory and anti-helicobacter drugs are advised post-operatively  . Omeprazole, a proton-pump inhibitor drug seems to be effective in this regard.
A history of previously treated duodenal ulcer or an absence do not preclude the diagnosis of perforated duodenal ulcer in cases of sudden, severe, acute abdomen. Most cases of perforated duodenal ulcer have no previous history of duodenal ulcer.
When there are contraindications to surgical treatment, perforated duodenal ulcer can be managed successfully by an aggressive conservative treatment.
Contrary to expectation the incidence of perforated duodenal ulcer does not increase during the fasting month of Ramadhan.
|1||Wastell C. Duodenal ulcer: A disappearing disease. Postgrad Surg. 1992;2:30-4.|
|2||Ajao OG. Perforated duodenal ulcer in a tropical African population. J Natl Med Assoc. 1979;71:272-3.|
|3||Pension JG, Crombie IK, Waugh NR, Wormsley KG. Trends in morbidity and mortality from peptic ulcer disease. Tayside versus Scotland. Aliment-Pharmacol-ther. 1993;7:429-42.|
|4||Lee FI, Hardman M, Jaderberg ME. Maintenance treatment of duodenal ulcertion:ranitidine 300 mg at night is better than 150 mg in cigarette smokers. Gut 1991; 32:15 1-3.|
|5||Hansell DT, McGushin M, Meddings RN, Smith IS, Gray GR, Gillespie G. Maintenance cimetidine instead of surgery for duodenal ulcer: the first decade. Gut 1989;30:786-9.|
|6||Delchier JC, Isal JP, Eriksson S, Soule JC. Double blind multicenter comparison of omeprazole 20 mg once daily versus ranitidine 150 mg twice daily in the treatment of cimetidine or ranitidine resistant duodenal ulcers. Gut 1989; 30:1173-8.|
|7||Lee CW, Yip AW, Lam KH. Pneumogastrogram in the diagnosis of perforated peptic ulcer. Aust N Z J-Surg. 1993;63:459-61.|
|8||Raafat NA, Lee MJ, Dawson SL, Mueller PR. Case report: Combined conservative and percutaneous management of a perforated duodenal ulcer. Clin Radiol. 1993;47:426-8.|
|9||Cocks JR. Perforated peptic ulcer - the changing scene. Diag Dis. 1992;1:10-6.|
|10||De BoerW, et al. Effect of acid suppression on efficacy of treatment for Helicobacter pylori infection. Lancet 1995; 345:817-20.|
|11||Louw JA, et al. Helicobacter pylori eradication in the African setting with special references to reinfection and duodenal ulcer recurrence. Gut 1995;36:544-7.|
|12||Clinical Quiz. Med Digest 1996;22:25-6;55-6.|
|13||Boey J, Chois, Algaratman TT, et al. Risk stratification in perforated peptic duodenal ulcelrs: a prospective validation of predictive factors. Am J Surg 1987,205:22-6.|
|14||Cellan-Jones CJ. A rapid method of treatment in perforated duodenal ulcer. BMJ 1929;1:1076.|
|15||Karanjia ND, Shanahan DJ, Knight MJ. Omental patching of a large perforated duodenal ulcer: a new method. Br J Surg 1993;80:65.|
|16||Mouret P, Francois Y, Vignal J, Barthy, Lombard-Platet R. Laparoscopic treatment of perforated peptic ulcer. Br J Surg 1990;77:1006.|
|17||Saunderland GT, Chisholm EM, Lau WY, Chung SCS, Li AKC. Laparoscopic treatment of perforated peptic ulcer. Br J Surg 1992;79:785.|
|18||Scott HJ, Rosin RD. The influence of diagnostic and therapeutic laparoscopy on patients presenting with an acute abdomen. J R Soc Med 1993;86:699-701.|
|19||Sigman HH, Garzon J, Marelli D. Laparoscopic closure of perforated duodenal ulcer. J Laparoendosc Surg 1992;2:325-7.|
|20||Urbano D, Rossi M, De-Simone P, Berloco P, Al Fani D, Cortesini R. Alternative laparoscopic management of perforated peptic ulcers. Surg - Endosc. 1994;8:1208-11.|
|21||Tschudi J, Wagner M, Klaiber C. Laparoscopic suturing of a perforated gastroduodenal ulcer. Schweiz-Med-Wochenschr 1994;124:1281-3.|