Manejo de las úlceras pépticas perforadas. Años 2005 a 2013 / Management of ulcers peptic perforated. Years 2005-2013

La perforación de úlceras pépticas se presenta del 1 al 6% de los pacientes ulcerosos, infrecuente, pero representa una complicación grave con morbi-mortalidad elevada. Objetivo: Determinar la frecuencia de úlcera péptica perforada (UPP) en los abdómenes agudos, factores predisponentes, tratamiento, morbilidad y mortalidad. Pacientes y método: Trabajo descriptivo, retrospectivo, observacional de pacientes que consultaron en urgencias, con diagnóstico de UPP en la IICCQ; marzo-2005 a diciembre-2013. Resultados: Ingresaron 308 pacientes con abdomen agudo quirúrgico, 30 (9,7%) con diagnóstico de UPP; 27 varones y 3 mujeres, edad promedio 54 (26-82 años). Tiempo de evolución en promedio de 14hs (4-72hs). Los síntomas predominantes fueron: dolor abdominal, náuseas y vómitos. Factores predisponentes: consumo de AINES, etilismo y tabaquismo. El diagnóstico se realizó por clínica, radiografía de tórax (neumoperitoneo) y en algunos casos de manera intraoperatoria. El tratamiento quirúrgico consistió en sutura primaria y epiploplastia en 27 casos; 2 casos, antrectomía y gastro-yeyunoanastomosis en Y de Roux y 1 caso, resección en cuña de la úlcera y sutura primaria. La localización de la úlcera fue: 13 casos en región prepilórica; 7 en antro; 4 en píloro; 3 en primera porción duodenal y 3 en cuerpo gástrico. El tamaño de la misma fue entre 0,5-4 cm de diámetro. Complicaciones registradas: 3 casos de atelectasia; 3 de neumonía intrahospitalaria; 3 de infección de herida operatoria, 1 de inestabilidad hemodinámica; 1 laceración hepática; 2 evisceraciones; 1 fístula enterocutánea y 2 de infección de vías urinarias. La mortalidad fue de 6,6%, (2 casos); uno por sepsis de origen abdominal y otro por hemorragia digestiva alta masiva.La UPP corresponde a un cuadro grave. El tratamiento quirúrgico es la terapia de elección para el episodio agudo. A pesar de la gravedad, no registramos mortalidad elevada con respecto a otras series.

Perforation of peptic ulcers occurs from 1 to 6% of the ulcer, rarely, but represents a serious complication with high morbidity and mortality. Objective: To determine the frequency of perforated peptic ulcer (PPU) in acute abdomens, predisposing factors, treatment, morbidity and mortality. Patients and Methods: Research descriptive, retrospective and observational, at the emergency room with patients diagnosed with UPP in IICCQ; Mar-2005 to December-2013. Results: 308 patients were admitted with acute abdomen, 30 (9.7%) diagnosed with UPP; 27 men and 3 women, mean age 54 (26-82 years). Time evolution of average 14hs (4-72hs). The predominant symptoms were abdominal pain, nausea and vomiting. Predisposing factors: NSAID, alcohol consumption and smoking. The diagnosis was made by clinical, chest radiography (pneumoperitoneum) and in some cases intraoperatively. Surgical treatment consisted of primary suture and epiploplasty in 27 cases; 2 cases, gastroyeyunoanastomosis antrectomy and Roux-Y and 1 case, wedge resection of the ulcer and primary suture. The location of the ulcer was: 13 cases in prepyloric region; 7 in the antrum; 4 in pylorus; 3 in the first duodenal portion and 3 in the gastric body. Same size was between 0.5-4 cm in diameter. Complications recorded 3 cases of atelectasis; 3 of nosocomial pneumonia; 3 of wound infection, 1 of hemodynamic instability; 1 liver laceration; 2 evisceration; 1 3 enterocutaneous fistula and 2 urinary tract infection. The mortality was 6.6% (2 cases); one abdominal sepsis and another massive upper gastrointestinal bleeding. The UPP is for a severe case. Surgical treatment is the therapy of choice for acute episode. Despite the seriousness, not checking high mortality compared with other series.

Perforated peptic ulcer a review of 36 cases

To evaluate the epidemiology of peptic ulcer perforation in Armed Forces and further management / outcome of the patients. Data of 36 patients with perforated peptic ulcer collected. This data was analyzed on SPSS 13. CMH Rawalpindi from Jan 1979 to July 1981, Jan 1985 to Dec 1987 and Jan 2001 to Dec 2003. Out of 36 patients 35 were male and only one was female. Twenty four [67%] were between 31-50 years. No past history was taken from eight [22%] patients. Thirty four [94%] patients presented with duodenal perforation. Twenty patients [55%] had rigidity all over abdomen and peristalsis were present in ten [28%] patients who reported within twelve hours. Seventy eight [78%] were diagnosed by history and simple radiological examination. All the patients were treated by laparotomy [simple closure with omental patch]. Post operative complications occur in ten [28%] patients and mortality rate was 8%. Predominantly the peptic ulcer perforation occurs between 30-50 years of age. The incidence reduces with succeeding years of study. Post operative complications were less in younger age group .Early diagnosis can be made easily by taking good history and performing simple radiological examination

Fatal gastro-duodenal perforation following electrocution: A case report.

A 45 yrs old male was accidentally electrocuted, while cooking on a locally made heater in his home. He was immediately brought to the hospital in unconscious state by the family members. After first aid he was referred to a tertiary care hospital, where he was admitted about two hrs after the incident. On admission he was unconscious, abdomen was distended, with fluid in peritoneal cavity. There was tachycardia and hypotension. Bowel sounds were absent. Electrocution burn marks were present over the right hand. Arterial blood analysis showed severe metabolic acidosis. He was immediately shifted to the ICU. His condition continued to be critical with persistent metabolic acidosis despite repeated sodium bicarbonate infusion. An exploratory laprotomy was planned to rule out abdominal visceral injuries. However the patient expired six hrs after admission to the hospital before being taken to the operation theatre. Autopsy examination showed perforated anterior wall of stomach antrum and first part of duodenum.

Primary closure of perforated peptic duodenal ulcer

To find out the morbidity and mortality of primary Closure of perforated peptic duodenal ulcer with an omental patch. An observational descriptive study, from February 2003 to January 2006. This study is Carried out in Surgical units of People's Medical College Hospital Nawabshah on 92 patients of perforated duodenal ulcer were included in this study with male to female ratio 8:1. The age varies between 26-45 year with peak age incidence 35 years. The perforation closed primarily with vicry1-0 and supported with omental patch. Peritoneal lavage performed and drain kept in all cases. All patients were investigated for H. pylori and treated with eradication therapy in infected cases. Follow up carried out with upper G.I. Endoscopy at 6 weeks, and then six monthly for two years. Out of 92 cases, only 5 cases had recurrence within two years and wound infection remained the major post operative complication seen in 20% and chest infection in 15% of cases. No mortality seen in this study. Omental patch repair as primary closure of perforated peptic duodenal ulcer is effective surgical treatment with excellent results. The eradication therapy for H. pylori is adequate and comparable with definitive surgical treatment for peptic ulcer

Factors influencing mortality in perforated duodenal ulcer following emergency surgical repair.

Duodenal perforation is a common abdominal catastrophe with excellent outcome if prompt resuscitation and surgical repair of perforation are done. The aim of this study was to identify factors associated with death after surgery in patients with duodenal perforation. One hundred and forty-five patients who underwent Graham's patch repair for perforated duodenal ulcer between 14 April 2002 and 31 December 2004 were studied. The mean age was 45.99 years and 61 patients (42.07 %) were referrals. There were 124 (85.52 %) males and 21 (14.48 %) females. There were 10 deaths (6.9 %). The mean time delay was 2.46 days. It was 2.37 days in survivors, 3.7 days in non-survivors. The time delay was 3.25 days for females and 3.13 days for patients referred from another hospital. The mortality was significantly associated with time delay between perforation and operation (p<0.01), presence of co-morbid conditions (P<0.04), respiratory rate (p<0.02), raised blood urea (p<0.01) and serum creatinine (p<0.001), size of perforation (p<0.005), amount of peritoneal fluid (p=0.003) and requirement of postoperative intensive care unit support (p=0.003). Time delay between perforation and operation, preoperative blood urea and serum creatinine, size of perforation and amount of peritoneal fluid, presence of co-morbid conditions and need for post operative ICU support are the important predictors of outcome after emergency surgery for duodenal perforation.

Estado actual del tratamiento quirúrgico de la úlcera péptica perforada en el Hospital Regional de Talca: Experience of a regional hospital / Emergency surgical treatment of perforated peptic ulcer

La perforación de una úlcera péptica corresponde a una infrecuente y siempre grave complicación de la enfermedad ulcerosa. El tratamiento quirúrgico es la terapia de elección. Se operaron 22 pacientes (21 hombres) con una edad promedio de 50 años. Tres enfermos tenían el diagnóstico de úlcera péptica previo a la emergencia actual. El síntoma más frecuente de consulta fue el dolor epigástrico de inicio súbito en 21 (95,4 por ciento) pacientes. El diagnóstico se realizó con radiografía de tórax de pie o de abdomen simple en 11 enfermos. Se realizó sutura simple de la úlcera en 12 (54,5 por ciento) pacientes, sutura más epiploplastía en 7 (31,8 por ciento) y resección gástrica en tres enfermos (13,6 por ciento). Siete (31,8 por ciento) pacientes presentaron complicaciones post operatorias, de los cuales fallecieron 2 (9,1 por ciento) como consecuencia de la sepsis asociada. Se realizó un seguimiento endoscópico a 9 pacientes (45 por ciento) sobrevivientes al episodio agudo. En 5 de ellos se demostró que la úlcera péptica aun permanecía activa. A dos de estos últimos pacientes se les realizó, en forma electiva una cirugía resectiva definitiva. Se concluye que la perforación de una úlcera péptica corresponde a un cuadro grave, que se asocia a una morbilidad y mortalidad significativa. El tratamiento quirúrgico local es la terapia de elección para el episodio agudo, sin embargo este no es definitivo y no evita la recidiva.

Background: Peptic ulcer perforation is an uncommon by devastating complication that requires emergency surgical treatment. Aim: To review the results of surgical treatment of peptic ulcer perforation in a Chilean Regional Hospital. Material and Methods: Retrospective review of medical records of 22 patients (age range 21-88 years, 21 males) operated for a perforated peptic ulcer, between 1995 and 2000. Results: The most common presentation symptom was acute epigastric pain in 21 patients. The diagnosis was done with a plain abdominal X ray obtained in the standing position, in 11 patients. A simple suture of the ulcer was done in 12 patients, suture plus epiploplasty in seven and gastric resection in three. Seven patients (32 percent) had postoperative complications and two (9 percent) died as a consequence of an associated septic process. An endoscopic follow up was done in nine patients and in two, the peptic ulcer remained active. These two patients were subjected to an elective excisional surgery. Conclusions: Local surgical correction of peptic ulcer perforation is the emergency treatment of choice but does not avoid ulcer relapse.

Risk factors predicting operative mortality in perforated peptic ulcer disease.

Following the introduction of H2-blockers and proton pump inhibitors, there has been a sharp decrease in elective peptic ulcer surgery. However, emergency operations for complications such as perforation are on the rise. This study was undertaken to review the factors which determine mortality following emergency surgery for peptic ulcer perforation. A prospective study of all patients who underwent surgery at our institute for peptic ulcer perforation between September 1999 and August 2001 was carried out. One hundred seventy-four patients underwent surgery for perforated peptic ulcer. Risk of death was related to age more than 60 years, shock at presentation, delay more than 24 hours prior to surgery and size of perforation more than 5 mm. Perforated peptic ulcer disease remains a frequent clinical problem associated with a significant postoperative mortality.

A simplified prognostic scoring system for peptic ulcer perforation in developing countries.

BACKGROUND: Several complex prognostic scoring systems are available for abdominal sepsis. We constructed and assessed a simplified scoring system for peptic perforation, which can be easily used in developing countries. METHODS: One hundred and forty consecutive patients with perforated pre-pyloric or duodenal ulcer undergoing Graham's patch omentopexy closure were studied prospectively. Each factor was given a score based on its severity in accordance with the APACHE-II scoring system to construct the simplified prognostic (Jabalpur) scoring system, and multiple regression analysis was used to identify risk factors. This system was prospectively validated in the next 50 consecutive patients and compared to existing systems. RESULTS: The factors associated with mortality were age, presence of co-morbid illness, perforation-to-operation interval, preoperative shock, heart rate, and serum creatinine. The mean score in survivors (4.9) was less than that in those who died (12.5; p<0.0001). This scoring system compared favorably with other scoring systems. CONCLUSIONS: The Jabalpur scoring system is effective for prognostication in cases of peptic perforation. It is simple and user-friendly as it uses only six routinely documented clinical risk factors.

Non - operative management of perforated peptic ulcer

The aim of this study was to see the morbidity and mortality in peptic ulcer perforation cases by non-operative management in selected cases. Design: The cases were selected on the basis of structured protocol. Setting: This study was carried out in the Department of Surgery of Khulna Medical College Hospital located in southern Bangladesh over a period of 10 years. Subjects: The patients were diagnosed as perforated peptic ulcer clinically and radiologically. All patients in this series had pneumoperitoneum in plain x-ray abdomen. They included 54 patients of peptic ulcer perforation cases had the following parameters: early presentation [<12 hours], soft abdomen with minimum tenderness and relatively younger patients. All patients were chosen who were haemodynamically stable. Ultrasonography was done in doubtful cases and also to see the amount of free fluid inside the abdominal cavity. Methodology: After diagnosis, all patients were managed in a similar fashion-like nil by mouth, continuous gastric aspiration, application of intravenous fluids and antibiotics and antiulcer therapy. In the selected 54 patients, male: female were 49:05. Nine had history of NSAID intake. There was no mortality. Morbidity analysis showed that three had hepatic abscess, four had pelvic abscess, six took prolonged time for improvement, in two cases conservative treatment had to be abandoned and laparotomy was done in the same hospital admission. Non-operative procedure is a safe and effective measure for the management of perforated peptic ulcer in selected cases

Peptic duodenal perforation-an audit

This study was carried out from November 1996 to August 1998 in the Surgery Department of Sandeman Provincial Teaching Hospital, Quetta, on a total of 40 patients hospitalized with peptic duodenal perforation. The major- of the patients [92.5%] was below 50 years of age with peak incidence in the third decade of life [32.5%]. The mean standard deviation of patients' age was 31.4 ' 13.3 years and male to female ratio was 12.3:1. The incidence among males was 9 per 1000 patients and in female 1 per 1000 patients. The overall incidence was 7 per 1000 patients. The majority of the patients [82.5%] came within 48 hours. The median duration of perforation was 40 hours. In all the patients there was a single perforation at the first part of duodenum on anterior surface. The median size was 4.5 mm. Simple closure with viable omental patch repair was performed in all the cases. Patients with longer duration of perforation had increase morbidity to wound and respiratory tract infections [P<0.001 by Chi sq test]. Most of the patient remain admitted for less than 10 days. Their median hospital stay was 14.5 days with minimum stay of 6 days and maximum stay of 32 days. The overall mortality was [7.5%] attributed to old age, leakage from repair site and associated medical illnesses. The duration of perforation had no effect on mortality in this study

Duodenal ulcer perforation: have H2 receptor blockers reduced mortality?

Elective surgery for peptic ulcer is becoming rare with the use of more effective medical therapy. However, life threatening complications have not reduced in number. A retrospective study was carried out to compare perforation rates per 10,000 admissions, mortality rates from perforated duodenal ulcers per 10,000 admission and the proportion of patients with perforated duodenal ulcer who died, before and after the introduction of H2 receptor blockers in a large teaching hospital in South India. Perforation rates were not significantly different between the two periods under study. There was a small, but statistically significant (p = 0.047) drop in mortality per 10,000 admissions and a significant drop in proportion of patients with perforated ulcer who died (p = 0.028). Inspite of effective medical therapy, there is a subset of patients with duodenal ulcer who continue to perforate. Efforts should be directed towards identifying this subset and offering them early surgery. Mortality rates have not changed significantly.

Simple closure of perforated duodenal ulcer.

A study was undertaken to evaluate the efficacy of simple closure followed by drug therapy in cases of perforated duodenal ulcer and to identify the risk factors in relation to the mortality. The male to female ratio was 5:1. Of the patients 59.2% were up to 50 years of age, while 40.8% were above the age of 50 years. Of the patients 47% were admitted 24 hours after the onset of peritonitis. All these patients were surgically treated with simple closure of the perforation with omental patch. Nine patients expired leading to 7.5% mortality. The risk factors identified for mortality were age 60 years and above, presence of shock on admission and delayed presentation. The mortality is directly related to the number of risk factors present in a given patient. At the time of discharge the patients were advised to take orally famotidine 40 mg at bed time for a period of 8 weeks. Eighty-one patients could be followed up and Visick grading was done. Sixty-two patients were in grade I, 11 in grade II, 3 in grade III and 5 in grade IV. The results indicate that simple closure followed by drug therapy is acceptable treatment for perforated duodenal ulcer.

Riscos em cirurgia gastroduodenal de emergência e urgência: morbidade e mortalidade: análise de 76 casos / Risk in emergencie gastroduodenal surgery: morbidadity and mortality: analisis of 76 cases

O autor apresenta 76 casos onde o risco cirúrgico é aumentado devido à urgência e emergência, como também às alteraçöes fisiopatológicas que daí decorrem. A mortalidade e morbidade säo elevadas nestes casos.

Resultados inmediatos del tratamiento quirúrgico de la úlcera péptica gastroduodenal perforada / Inmediate results of surgical treatment of perforated peptic gastroduodenal ulcer

Se realizó un estudio multicéntrico en un período de 2 años (1988-1990) en 9 hospitales clinicoquirúrgicos del país, sobre el tratamiento quirúrgico de la úlcera péptica gastroduodenal. Se analizaron en total 729 encuestas de pacientes operados por esta causa, de los cuales, 399 recibieron tratamiento quirúrgico de forma electiva y el resto de urgencia. De estas últimas, 211 correspondieron a la úlcera péptica gastroduodenal perforada; en el 91,0 por ciento de las mismas se practicó sutura y epiploplastia, mientras que en el grupo restante se aplicaron otras técnicas: el 28,9 por ciento de los enfermos se complicó y la mortalidad se elevó al 20,4 por ciento , lo que pone en evidencia la gravedad de esta complicación

Ulcera péptica perfurada: experiência de um serviço / Perforated peptic ulcer: experience of a service

O objetivo deste trabalho é analisar, retrospectivamente, a experiência de um Serviço no tratamento de úlcera péptica perfurada. Para tanto säo estudados cinquenta casos desta patologia, tendo sido 29 úlceras gástricas e 21 duodenais. A rafia com epiploomplastia foi a cirurgia escolhida em 40 (80 por cento) situaçöes, enquanto que cirurgias mais extensas foram realizadas nos 10 (20 por cento) casos restantes. A mortalidade foi de 14 por cento para as úlceras duodenais perfuradas e mais expressiva quando cirurgias mais extensas foram realizadas. A taxa de óbitos na úlcera gástrica foi de 10 por cento e em todos a rafia com epiploomplastia foi a cirurgia realizada. A associaçäo de fatores de risco foi elemento marcante naqueles pacientes que tiveram má evoluçäo.

Sociedad de Cirujanos de Mar del Plata: úlcera gastroduodenal perforada en pacientes mayores de 60 años / Surgeons' Society of Mar del Plata: perforated gastroduodenal ulcer in patients over 60 years age

La sociedad de Cirujanos de Mar del Plata nos ha hecho llegar los trabajos correspondientes al año 1990 que, según el jurado integrado por los Dres. Claudio Barredo, Jorge Defelitto y Alejandro Oria, fueron consderados como los de mayor valor en cuanto a la importancia del tema y la metodología empleada. Se publica a continuación el segundo y tercer trabajo

Alternativas no tratamento cirúrgico da úlcera gastroduodenal perfurada / Alternatives in the surgical treatment of perforated gastroduodenal ulcer

Os autores relatam os resultados imediatos de 26 casos de úlcera gastroduodenal perfurada atendidos no Hospital de Pronto Socorro da F.U.S.A.M., num período de três anos. A perfuraçäo ocorreu em mais da metade dos pacientes (57,7%) na face anterior do duodeno; a técnica cirúrgica preferencialmente utilizada foi a sutura da perfuraçäo associada ou näo à epiplopastia (46,2%). Ocorreram complicaçöes precoces e tardias em nove pacientes (34,5%), e a mortalidade operatória foi de 11,6%. Näo houve mortalidade nos pacientes situados na faixa etária inferior a 60 anos e operados em até 48 horas do início dos sintomas. Nesta série, os índices de complicaçöes e mortalidade relacionaram-se diretamente com a idade do paciente, o grau de contaminaçäo peritoneal e o período decorrido entre o início dos sintomas e a operaçäo, independentemente do tipo de cirurgia realizada ou da localizaçäo da perfuraçäo

Ulcera gastroduodenal perforada: morbilidad y mortalidad / Perforated gastroduodenal ulcer: morbidity and mortality

Se realiza un estudio de 50 pacientes a los que se les diagnosticó úlcera gastroduodenal perforada. Se analizan la frecuencia por edad, sexo, procedencia, localización, procederes quirúrgicos empleados y sus complicaciones secundarias, mortalidad en los pacientes operados y su causa directa. Se llega a conclusiones sobre métodos estadísticos. Se valora la necesidad de un programa de Educación para la Salud de estos pacientes en riesgo. Se revisa la literatura al respecto. Se establecen recomendaciones