Perforated peptic ulcer: different ethnic, climatic and fasting risk factors for morbidity in Al-ain medical district, United Arab Emirates

Seasonal Variation of Presentation of Perforated Peptic Ulcer Disease: An Overview of Patient Demographics, Management and Outcomes

Background

Perforated peptic ulcer disease (PUD) is one of the most common causes of acute peritonitis. It carries significant mortality and morbidity. Several previous studies have reported a seasonal variation in the presentation of patients with perforated ulcers. Here we present this study from our experience in a Northern Irish acute district hospital.

Methods

A retrospective cohort study was conducted on perforated peptic ulcer patients who presented to Altnagelvin Area Hospital emergency department between 2015 to 2020. Data on patient demographics, clinical presentation, investigations, management and outcomes were collected. Primary outcome was to investigate if seasonality was associated with the incidence of perforated peptic ulcers. Follow-up data were also collected. Seasons were defined as per UK Met Office.

Results

A total of 50 patients presented with perforated PUD. Male to female ratio was approximately 3:2. Peaks were noted in spring and winter. April was the most common month for presentation followed by December. Smoking was the most common risk factor followed by alcohol abuse. Fourteen patients (28%) were either very frail or had contained perforations and were conservatively managed. Three deaths were noted (6%). Thirteen patients (26%) required ICU admission at some stage in their management.

Conclusion

Slight seasonal variation was noted in the presentation of perforated peptic ulcers in our study with a higher incidence in the winter and spring months. The month of April was noted to have the peak incidence of the disease in our study.

Perforation of anastomotic peptic ulcer following pancreaticoduodenectomy: a report of three cases

BACKGROUND

Perforation of a marginal peptic ulcer after pancreaticoduodenectomy (PD) can lead to severe conditions, although its clinical features have not been well reported. In this article, we present three cases of marginal peptic ulcer perforation after PD that we experienced in our institute and attempt to clarify its appropriate treatment and prevention.

CASE PRESENTATION

Marginal ulcer perforation confirmed with computed tomography and/or surgical exploration occurred in 3 (1.8%) of 163 consecutive patients who underwent PD (including 160 patients who underwent a total or subtotal stomach-preserving procedure) at our institution. The three patients (one man and two women) had a median age of 77 (65-79) years. Two of these patients had a medical history of duodenal peptic ulcer. All three patients had biliary neoplasms. Two of the patients underwent subtotal stomach-preserving PD with antro-jejunal anastomosis, and the other patient underwent pylorus-preserving PD with duodenal jejunostomy. The perforation occurred with a sudden and severe onset of abdominal pain 34, 94, and 1204 days, respectively, after the PDs. At the time of the perforation, all of the patients had been withdrawn from postoperative prophylactic antipeptic ulcer agents, with the cessation periods ranging from 12 to 1008 days. In addition, all the patients were in fasting conditions for 1 to 13 days just before the perforation. Surgical treatment with direct suturing of the perforated ulcer was performed for two patients, while conservative therapy was performed for one patient. Their primary treatment courses were satisfactory. Chronic antisecretory agent therapy was prescribed for 562, 271, and 2370 days, respectively, from marginal ulcer perforation, and no ulcer recurrence was noted in any of the patients.

CONCLUSIONS

Lack of antisecretory therapy and fasting were considered an essential cause of marginal peptic ulcer perforation after PD. In addition, unlike the native duodenum, the jejunal limb used for reconstruction to a preserved stomach may be at increased risk of ulceration. Chronic permanent administration of antisecretory agents and fasting avoidance are desirable for patients who have undergone stomach-preserving PD to prevent marginal ulcer perforation.

Complicated intra-abdominal infections: a prospective validation study of the WSES Sepsis Severity Score

INTRODUCTION

The World Society of Emergency Surgery (WSES) recently developed and validated a sepsis severity score for complicated intra-abdominal infections (cIAIs). We aimed to prospectively study the validity of this score in our local setting and compare it with global findings.

METHODS

In a prospective study of 100 consecutive adult patients with cIAIs treated at Al-Ain Hospital, United Arab Emirates, from October 2014 to January 2016, we studied patients' demographics, disease, risk factors, WSES Sepsis Severity Score, management, hospital stay and mortality. Our findings were compared with those from a recent global multicentre prospective study from 53 countries (n = 4,496).

RESULTS

Compared with global data, our patients were more likely to be male (p < 0.0001) and younger (p < 0.0001), with more appendicitis and perforated peptic ulcers (p < 0.0001), significantly lower sepsis severity score (p < 0.0001) and more delays in surgical intervention (p = 0.001). Nevertheless, they had similar adequate source control (p = 0.54) and surgical reinterventions (p = 0.63). Overall, our patients had a significantly lower mortality rate (1.0% vs. 9.3% in global data; p = 0.001). A direct logistic regression model showed that the WSES Sepsis Severity Score significantly predicted mortality (p < 0.0001), but our hospital's setting was not predictive of mortality compared with other hospitals (p = 0.18).

CONCLUSION

Although our patient demographics and hospital's setting significantly differed from those of other international hospitals, the WSES Sepsis Severity Score was very accurate in predicting mortality among our patients, which supports its generalisability for all patient populations worldwide.

Clinical characteristics of peptic ulcer perforation in Korea

AIM

To elucidate the epidemiological characteristics and associated risk factors of perforated peptic ulcer (PPU).

METHODS

We retrospectively reviewed medical records of patients who were diagnosed with benign PPU from 2010 through 2015 at 6 Hallym university-affiliated hospitals.

RESULTS

A total of 396 patients were identified with postoperative complication rate of 9.1% and mortality rate of 0.8%. Among 174 (43.9%) patients who were examined for Helicobacter pylori (H. pylori) infection, 78 (44.8%) patients were positive for H. pylori infection, 21 (12.1%) were on non-steroidal anti-inflammatory drugs (NSAIDs) therapy, and 80 (46%) patients were neither infected of H. pylori nor treated by any kinds of NSAIDs. Multivariate analysis indicated that older age (OR = 1.09, 95%CI: 1.04-1.16) and comorbidity (OR = 4.11, 95%CI: 1.03-16.48) were risk factors for NSAID-associated PPU compared with non-H. pylori, non-NSAID associated PPU and older age (OR = 1.04, 95%CI: 1.02-1.07) and alcohol consumption (OR = 2.08, 95%CI: 1.05-4.13) were risk factors for non-H. pylori, non-NSAID associated PPU compared with solely H. pylori positive PPU.

CONCLUSION

Elderly patients with comorbidities are associated with NSAIDs-associated PPU. Non-H. pylori, non-NSAID peptic ulcer is important etiology of PPU and alcohol consumption is associated risk factor.

Prognostic factors in peptic ulcer perforations: a retrospective 14-year study

Regarding the complications of peptic ulcer, a perforation remains the most important fatal complication. The aim of our retrospective study was to determine relations between postoperative morbidity and comorbid disease or perioperative risk factors in perforated peptic ulcer. In total, 239 patients who underwent emergency surgery for perforated peptic ulcer in Ege University General Surgery Department, between June 1999 and May 2013 were included in this study. The clinical data concerning the patient characteristics, operative methods, and complications were collected retrospectively. One hundred seventy-five of the 239 patients were male (73.2%) and 64 were female (26.8%). Mean American Society of Anesthesiologists (ASA) score was 1 in the patients without morbidity, but mean ASA score was 3 in the morbidity and mortality groups. Primary suture and omentoplasty was the selected procedure in 228 of the patients. Eleven patients underwent resection. In total, 105 patients (43.9%) had comorbidities. Thirty-seven patients (67.3%) in the morbidity group had comorbid diseases. Thirteen (92.9%) patients in the mortality group had comorbid diseases. Perforation as a complication of peptic ulcer disease still remains among the frequent indications of urgent abdominal surgery. Among the analyzed parameters, age, ASA score, and having comorbid disease were found to have an effect on both mortality and morbidity. The controversial subject in the present study is regarding the duration of symptoms. The duration of symptoms had no effect on mortality nor morbidity in our study.

Strategies to improve the outcome of emergency surgery for perforated peptic ulcer

BACKGROUND

Perforated peptic ulcer (PPU) is a common surgical emergency that carries high mortality and morbidity rates. Globally, one-quarter of a million people die from peptic ulcer disease each year. Strategies to improve outcomes are needed.

METHODS

PubMed was searched for evidence related to the surgical treatment of patients with PPU. The clinical registries of trials were examined for other available or ongoing studies. Randomized clinical trials (RCTs), systematic reviews and meta-analyses were preferred.

RESULTS

Deaths from peptic ulcer disease eclipse those of several other common emergencies. The reported incidence of PPU is 3.8-14 per 100,000 and the mortality rate is 10-25 per cent. The possibility of non-operative management has been assessed in one small RCT of 83 patients, with success in 29 (73 per cent) of 40, and only in patients aged less than 70 years. Adherence to a perioperative sepsis protocol decreased mortality in a cohort study, with a relative risk (RR) reduction of 0.63 (95 per cent confidence interval (c.i.) 0.41 to 0.97). Based on meta-analysis of three RCTs (315 patients), laparoscopic and open surgery for PPU are equivalent, but patient selection remains a challenge. Eradication of Helicobacter pylori after surgical repair of PPI reduces both the short-term (RR 2.97, 95 per cent c.i. 1.06 to 8.29) and 1-year (RR 1.49, 1.10 to 2.03) risk of ulcer recurrence.

CONCLUSION

Mortality and morbidity from PPU can be reduced by adherence to perioperative strategies.

Incidence and short-term mortality from perforated peptic ulcer in Korea: a population-based study

Background

Perforated peptic ulcer (PPU) is associated with serious health and economic outcomes. However, few studies have estimated the incidence and health outcomes of PPU using a nationally representative sample in Asia. We estimated age- and sex-specific incidence and short-term mortality from PPU among Koreans and investigated the risk factors for mortality associated with PPU development.

Methods

A retrospective population-based study was conducted from 2006 through 2007 using the Korean National Health Insurance claims database. A diagnostic algorithm was derived and validated to identify PPU patients, and PPU incidence rates and 30-day mortality rates were determined.

Results

From 2006 through 2007, the PPU incidence rate per 100 000 population was 4.4; incidence among men (7.53) was approximately 6 times that among women (1.24). Incidence significantly increased with advanced age, especially among women older than 50 years. Among 4258 PPU patients, 135 (3.15%) died within 30 days of the PPU event. The 30-day mortality rate increased with advanced age and reached almost 20% for patients older than 80 years. The 30-day mortality rate was 10% for women and 2% for men. Older age, being female, and higher comorbidity were independently associated with 30-day mortality rate among PPU patients in Korea.

Conclusions

Special attention should be paid to elderly women with high comorbidity who develop PPU.

Preoperative prognostic factors for mortality in peptic ulcer perforation: a systematic review

OBJECTIVE

Mortality and morbidity following perforated peptic ulcer (PPU) is substantial and probably related to the development of sepsis. During the last three decades a large number of preoperative prognostic factors in patients with PPU have been examined. The aim of this systematic review was to summarize available evidence on these prognostic factors.

MATERIAL AND METHODS

MEDLINE (January 1966 to June 2009), EMBASE (January 1980 to June 2009), and the Cochrane Library (Issue 3, 2009) were screened for studies reporting preoperative prognostic factors for mortality in patients with PPU. The methodological quality of the included studies was assessed. Summary relative risks with 95% confidence intervals for the identified prognostic factors were calculated and presented as Forest plots.

RESULTS

Fifty prognostic studies with 37 prognostic factors comprising a total of 29,782 patients were included in the review. The overall methodological quality was acceptable, yet only two-thirds of the studies provided confounder adjusted estimates. The studies provided strong evidence for an association of older age, comorbidity, and use of NSAIDs or steroids with mortality. Shock upon admission, preoperative metabolic acidosis, tachycardia, acute renal failure, low serum albumin level, high American Society of Anaesthesiologists score, and preoperative delay >24 h were associated with poor prognosis.

CONCLUSIONS

In patients with PPU, a number of negative prognostic factors can be identified prior to surgery, and many of these seem to be related to presence of the sepsis syndrome.