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Perforated Peptic Ulcer

Peptic Ulcer Perforation

Perforated peptic ulcer is a complication of peptic ulcer disease. It is associated with a high incidence of mortality and morbidity if there is a delay in the diagnosis. Clinical suspicion, history, and examination findings along with imaging studies are necessary for detecting this condition early.


Presentation

Perforated peptic ulcer (PPU) is a comparatively rare complication of peptic ulcers and is associated with a mortality rate of up to 40% [1] [2] [3] [4]. The incidence of PPU has decreased in the Western countries but it may be encountered more frequently amongst the elderly [5], and especially in females [4]. Long-standing treatment with non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, H. pylori infection, smoking and high intake of dietary salt [2] [6] are reported to be some of the etiological factors leading to PPU. Advancing age, serious medical comorbidities, hypotension [7], diagnosis and treatment delays for more than one day [8] are indicators of poor prognosis.

PPU presents typically with sudden onset of severe epigastric pain which soon progresses to generalized abdominal pain. The patient may like to lie still as the movement may aggravate pain. The subsequent clinical symptoms depend upon whether the omentum is able to seal off the perforation and heal it. 'Board-like abdominal rigidity' can develop in patients and localized or generalized peritonitis progresses. [9]. At this time, the patient may present with hypotension, high-grade fever [5], altered sensorium and sepsis [9]. Typical clinical manifestations can be absent in older patients or those who are immunocompromised. This can delay the diagnosis and result in high rates of mortality.

Fever
  • There were also four significantly different variables between them: fever, hemoglobin value, site of perforation and operative method. Total postoperative complication rate was 41.3% and 39 patients (16.6%) died.[ncbi.nlm.nih.gov]
  • On admission, no fever was noted, the abdomen was flat and extremely hard, tenderness was noted, and peritoneal rebound was absent. Laboratory data on admission were all normal except for a slightly elevated CRP level.[ncbi.nlm.nih.gov]
  • Before he developed abdominal distension, the patient had suffered from an upper respiratory tract infection with fever for about 2 weeks, which was treated intermittently with ibuprofen.[ncbi.nlm.nih.gov]
  • The following factors were analyzed: patient profile, associated medical illnesses, diagnostic methods, fever, preoperative shock, clinical data from the emergency room, delays in surgery, sites of perforation, operative methods, positive ascites culture[ncbi.nlm.nih.gov]
  • May or may not have fever. Tachycardia Anxious _ uncomfortable in pain. Finding: Palpation : Tenderness (Severe). Rebound tenderness Rigidity: Often described as board like rigidity. (Rather classic).[medindia.net]
Severe Pain
  • This causes severe pain due to peritonitis. The pain is so intense that patient is often able to recollect the exact time and place it started. Pain is constant and spreads to the entire abdomen.[tandurust.com]
  • The first symptom of a perforated peptic ulcer is usually intense and severe pain.[yourfibrosupport.com]
  • Symptoms Sudden, sharp and severe pain in upper abdomen Spreading of pain to rest of abdomen Pain gets worse after oral ingestion or movements Feeling of giddiness and fainting Fever Weakness Signs Tachycardia Fever Pallor Reduced abdominal wall movements[speciality.medicaldialogues.in]
  • Severe pain, systemic inflammatory response from chemical peritonitis and fluid deficit either due to poor intake or vomiting or pyrexia leads to compensatory tachycardia.[wjgnet.com]
  • This usually causes severe pain and is a medical emergency. What tests may be done? Gastroscopy (endoscopy) is the test that can confirm a duodenal ulcer .[patient.info]
Pseudotumor
  • Sealed perforated ulcer with pseudotumor formation is very rarely encountered. Here we present a case of gastric pseudotumor induced by perforation of a peptic ulcer.[ncbi.nlm.nih.gov]
Abdominal Pain
  • The presence of early postoperative complications is associated with time of onset of abdominal pain before admission, abdominal distension, blood type O positive and the presence of septic shock on admission.[ncbi.nlm.nih.gov]
  • PPU should be suspected in adolescents who manifest acute abdominal pain and have peritoneal signs. Children with PPU have a more favorable outcome than adults.[ncbi.nlm.nih.gov]
  • A case of perforated peptic ulcer in a patient with cervical myelopathy due to osteophyte cervical canal stenosis complicated by the sudden onset of abdominal pain is described.[ncbi.nlm.nih.gov]
  • Severe abdominal pain in an ill-appearing child with a rigid abdomen and possibly with signs of shock is the typical presenting feature of this life-threatening complication of peptic ulcer disease.[ncbi.nlm.nih.gov]
  • The most common presenting symptom was abdominal pain in 76 (100%) patients. History of smoking and khat chewing was documented in 53/64 (82.8%) and 48/64 (75%) of the patients respectively.[ncbi.nlm.nih.gov]
Acute Abdomen
  • CONCLUSION: Perforated peptic ulcer disease is emerging as a frequent cause of acute abdomen in our centre and affects the youth commonly.[ncbi.nlm.nih.gov]
  • Perforation of peptic ulcer is one of the causes of acute abdomen in which early diagnosis and treatment dramatically decrease morbidity and mortality [ 1 ].[gynecolsurg.springeropen.com]
  • Although sonography is useful as a first-line diagnostic tool for acute abdomen in the emergency department, it is less helpful in the diagnosis of peptic ulcer perforation.[academic.oup.com]
  • Perforation of peptic ulcer : Perforation of peptic ulcer usually presented as an acute abdomen. Nearly one third of the patients have no history of the disease.[laparoscopyhospital.com]
Epigastric Pain
  • The majority of patients give a history of indigestion or epigastric pain typical of a duodenal or gastric ulcer.[gpnotebook.co.uk]
  • ABC Look for S/S of hypovolemia Start on O2 What might epigastric pain mimic? Maybe rigid, surgical abdomen Exquisite epigastric pain Pale, diaphoretic from shocky T/F: Like diarrhea, PUD can be clinically diagnosed.[quizlet.com]
  • Symptoms typically include burning epigastric pain that is often relieved by food. Diagnosis is by endoscopy and testing for Helicobacter pylori . Treatment involves acid suppression, eradication of H. pylori (if present), and avoidance of NSAIDs.[msdmanuals.com]
  • pain and excessive belching.[step2.medbullets.com]
  • The symptoms of a burst stomach ulcer include bleeding, epigastric pain, melena, narrowed digestive passages, sudden weight loss, loss of appetite and waterbrushes.[diethealthclub.com]
Severe Abdominal Pain
  • Severe abdominal pain in an ill-appearing child with a rigid abdomen and possibly with signs of shock is the typical presenting feature of this life-threatening complication of peptic ulcer disease.[ncbi.nlm.nih.gov]
  • The patient may have a history of peptic ulcer disease, but in about one-third of cases, the first symptom is a sudden attack of severe abdominal pain, usually epigastric, as well as reflected pain in another part of the abdomen.[gynecolsurg.springeropen.com]
  • The person experience severe abdominal pain. Pain may also be experienced while eating. Melena is extremely bad smelling feces. Waterbrushes is excessive saliva in the mouth.[diethealthclub.com]
  • A sign of a perforated ulcer is sudden, severe abdominal pain. Internal bleeding: Bleeding ulcers can result in significant blood loss and thus require hospitalization.[healthline.com]
  • Typically, initial symptoms begin with an onset of severe abdominal pain that is commonly epigastric in location, but becomes generalized as a chemical peritonitis ensues.[intjem.springeropen.com]
Abdominal Tenderness
  • This leads to not only pain but abdominal tenderness, meaning touching or pressing on the abdomen provokes increased pain.[livestrong.com]
  • Improvement is indicated by decrease in the pulse rate, temperature, and abdominal tenderness and by an improvement in the general well being of the patient.[ots1.narod.ru]
  • If the abdominal tenderness increases, the patient becomes hemodynamically unstable, or the contrast medium flows freely into the abdomen, then an operation is indicated. Operation in conservatively treated patients proceeds in 10% [ 6 ].[gynecolsurg.springeropen.com]
  • Abdominal tenderness and classical signs of peritonitis could be elicited in 88.1% and 66.7% of the patients with PPU in this study. Other symptoms also included nausea (35.7%), severe dyspepsia (33.3%), constipation (29.8%) and fever (21.4%)[ 50 ].[wjgnet.com]
Hypotension
  • Postoperative respiratory and renal failure were associated with intraoperative hypotension (systolic pressure less than 90 mm Hg). Mortality was associated with age greater than 55 and intraoperative hypotension.[ncbi.nlm.nih.gov]
  • In cases in which the patient presents more than 24 h after the onset of symptoms or shows the clinical signs of acute abdomen, hypotension, or sepsis, surgery should be done immediately [ 4 , 6 ].[gynecolsurg.springeropen.com]
  • Poor outcomes have been associated with increasing age, major medical illness, peri-operative hypotension [ 25 ], and delay in diagnosis and management (greater than 24 hours) [ 26 ].[wjes.biomedcentral.com]
  • In the third phase (more than 12 h), abdominal distension, pyrexia and hypotension with acute circulatory collapse may be evident.[wjgnet.com]
Tachycardia
  • Tachycardia Anxious _ uncomfortable in pain. Finding: Palpation : Tenderness (Severe). Rebound tenderness Rigidity: Often described as board like rigidity. (Rather classic).[medindia.net]
  • Pain was the consistent symptom while tachycardia, tenderness, and guarding were the signs present in all 70 (40%) patients. Gas under diaphragm (pneumoperitoneum) was found in 67 (95.71%).[scopemed.org]
  • The chemical peritonitis due to efflux of gastroduodenal contents and severe pain lead to tachycardia. The classic triad of sudden onset of abdominal pain, tachycardia and abdominal rigidity is the hallmark of PPU.[wjgnet.com]
  • His cardiovascular examination was remarkable for tachycardia, with regular and strong distal pulses in all four extremities.[intjem.springeropen.com]
Osteophyte
  • A case of perforated peptic ulcer in a patient with cervical myelopathy due to osteophyte cervical canal stenosis complicated by the sudden onset of abdominal pain is described.[ncbi.nlm.nih.gov]

Workup

A high index of clinical suspicion, a detailed history, and a thorough physical examination are vital for the early diagnosis of PPU. The patient may provide a history of partially treated peptic ulcer disease, recurrent epigastric pain, chronic intake of anti-ulcer medications, NSAIDS and/or steroids. Signs of peritonitis may be absent on physical examination, especially if the perforation gets sealed [10]. In advanced cases with sepsis, there may be tachycardia, hypotension and altered consciousness.

Laboratory tests are usually nonspecific with leukocytosis, elevated inflammatory markers, metabolic acidosis, and elevated levels of serum amylase suggestive of PPU [10]. Antibiotics should be started early in PPU but it is important to perform blood cultures prior to starting antibiotics [11] especially if bacterial peritonitis is suspected.

Plain X-ray chest or abdomen obtained in the upright position may show air under the diaphragm which is indicative of perforation of an abdominal organ. In the absence of pneumoperitoneum on plain X-ray, computed tomography (CT) scan with oral contrast is performed. It has a sensitivity of 98% and can also help to exclude other causes of the acute condition like pancreatitis [4] [12] [13]. PPU should be suspected if CT reveals pneumoperitoneum, thickening of the bowel wall, intraperitoneal fluid, fat streaking and/or hematoma in the mesentery and leak of contrast into the peritoneal cavity [14].

Pneumoperitoneum
  • The differential diagnosis of pneumoperitoneum in children is discussed, as are childhood perforated peptic ulcer in general, and the unique clinical features present in this case in particular.[ncbi.nlm.nih.gov]
  • The study showed pneumoperitoneum, contrast stasis in heart with decreased caliber of vessels below the abdominal aortic level, and diffuse lymphedema at the abdominal walls. Emergent laparotomy was performed.[ncbi.nlm.nih.gov]
  • Pneumoperitoneum and peritonitis were documented, but the symptoms were mild. The "board-like abdomen" sign was not noted.[ncbi.nlm.nih.gov]
  • Presenting symptoms were those of a perforated viscus, and pneumoperitoneum was present in all patients. Simple closure and omental patching of the ulcer resulted in no operative mortality or morbidity. None of the ulcers have recurred.[ncbi.nlm.nih.gov]
  • A plain abdominal radiograph revealed pneumoperitoneum with a football sign. At laparotomy, a 0.8-cm perforated hole was found over the prepyloric area. Simple closure with omental patching was performed after debridement of the perforation.[ncbi.nlm.nih.gov]

Treatment

  • Of these, 9 were about the history of treatment, 7 about conservative treatment, and 26 were about the surgical procedure of which 8 were addressing laparoscopic correction. Overall there is no consensus, but some advice is given.[ncbi.nlm.nih.gov]
  • Literature is scarce on this subject in the pediatric population and most articles describe a surgical treatment by laparotomy.[ncbi.nlm.nih.gov]
  • Laparoscopic treatment rate increased from 7% to 46% during the study period (p   0.02).[ncbi.nlm.nih.gov]
  • Morbidity and mortality could be reduced by avoiding delays in diagnosis and treatment, especially in older patients, and by instituting proper treatment of any coexisting medical illness.[ncbi.nlm.nih.gov]
  • Laparotomy has been the standard treatment for pyloroduodenal perforations caused by endoscopy. Laparoscopic repair is a well-documented treatment modality for spontaneously perforated peptic ulcer.[ncbi.nlm.nih.gov]

Prognosis

  • Tramadol's effect on peptic ulcer prognosis is unknown. The aim was to examine mortality in the 30 days following hospitalization for perforated peptic ulcer among tramadol and NSAID users compared with non-users.[ncbi.nlm.nih.gov]
  • Links: clinical features of perforated peptic ulcer epidemiology investigations management prognosis[gpnotebook.co.uk]
  • This improvement in the prognosis for patients with perforated peptic ulcer is the result, in large measure, of better operative technic, better anesthesia, a clearer knowledge of fluid balance and of blood replacement and the use of the antibiotics and[nejm.org]
  • Studies have suggested that up to 13% of patients receive inappropriate initial antibiotics, which may lead to a worse prognosis [ 13 , 21 ]. Emergent surgical consultation is required for operative repair of the site of bowel perforation.[intjem.springeropen.com]
  • Prognosis [ 5 ] Prognosis is excellent if the underlying cause such as H. pylori infection or drugs can be addressed. Eradication of H. pylori decreases the ulcer recurrence rate from 60-90% to 10-20%.[patient.info]

Etiology

  • .  There are two major etiologies of this imbalance: H. pylori infection and NSAID use.  H. pylori infection is present in 75% of gastric ulcers and greater than 90% of duodenal ulcers, Several recent meta-analyses demonstrated that there is a definite[slideshare.net]

Epidemiology

  • To investigate the epidemiological trends in incidence and mortality of perforated peptic ulcer (PPU) in a well-defined Norwegian population.[ncbi.nlm.nih.gov]
  • Links: clinical features of perforated peptic ulcer epidemiology investigations management prognosis[gpnotebook.co.uk]
  • A perforated peptic ulcer is the first differential diagnosis of pneumoperitoneum, but in the socio-epidemiological context of Togo, one should also consider typhoid.[medical-dictionary.thefreedictionary.com]
  • Peptic ulcer disease in low- and middle-income countries presents unique epidemiology and treatment challenges that may differ significantly from evidence-based guidelines in high-income countries.}, author {Moses, J.[lup.lub.lu.se]
  • OBJECTIVES: To determine the epidemiology of, and define the morbidity and mortality factors following emergency surgery for patients with perforated peptic ulcer disease in Accra, Ghana. DESIGN: A retrospective and prospective hospital-based study.[ncbi.nlm.nih.gov]
Sex distribution
Age distribution

Pathophysiology

  • In: Sleisinger MH, Fordtran JS (eds) Gastrointestinal diseases: pathophysiology, diagnosis, management, 5th edn. Saunders, Philadelphia, pp 580–679 Google Scholar Donovan AJ, Berne TV, Donovan JA (1998) Perforated duodenal ulcer.[gynecolsurg.springeropen.com]
  • Sleisenger and Fordtran's Gastrointestinal and Liver Disease: Pathophysiology/Diagnosis/Management . 10th ed. Philadelphia, PA: Elsevier Saunders; 2016:chap 51. Updated by: Michael M.[medlineplus.gov]
  • .  Antral D cells secrete somatostatin which inhibits gastrin production. 13. pathophysiology of peptic ulcer disease  Peptic ulcers occur when there is an alteration in the balance between acid production and mucosal protective mechanisms.  There[slideshare.net]

Prevention

  • To prevent or minimize leakage after simple closure of giant perforated peptic ulcers in critically ill elderly patients, we conducted a clinical study using gastric body partition to prevent upstream gastric juice and food from passing through the sutured[ncbi.nlm.nih.gov]
  • […] of Helicobacter pylori for prevention of ulcer recurrence after simple closure of perforated peptic ...[evidence.nhs.uk]
  • In this review we evaluate the existing evidence in order to identify significant risk factors with an emphasis on risks that are preventable. A systematic review including randomized studies was carried out.[ncbi.nlm.nih.gov]
  • A systematic review and meta-analysis of randomized controlled trials was performed to evaluate the effects of H pylori eradication on prevention of ulcer recurrence after simple closure of perforated peptic ulcers.[ncbi.nlm.nih.gov]
  • Patients with dyspeptic symptoms and a history of previous PUD should be considered for prophylactic treatment to prevent ulcer recurrence during prolonged daytime fasting in Ramadan, especially during the winter time.[ncbi.nlm.nih.gov]

References

Article

  1. Bertleff MJ, Lange JF. Perforated peptic ulcer disease: a review of history and treatment. Dig Surg. 2010; 27: 161-169.
  2. Lau JY, Sung J, Hill C, et al. Systematic review of the epidemiology of complicated peptic ulcer disease: incidence, recurrence, risk factors, and mortality. Digestion. 2011; 84: 102-113.
  3. Møller MH, Adamsen S, Wøjdemann M, Møller AM. Perforated peptic ulcer: how to improve outcome? Scand J Gastroenterol. 2009; 44: 15-22.
  4. Thorsen K, Glomsaker TB, von Meer A, Søreide K, Søreide JA. Trends in diagnosis and surgical management of patients with perforated peptic ulcer. J Gastrointest Surg. 2011; 15: 1329-1335.
  5. Hill AG. Management of perforated duodenal ulcer. Surgical treatment: evidence- based and problem -oriented. Holzheme RG, Mannick JA. eds. W. Zuckschwerdt Verlag GmbH, Munich;2001
  6. Gisbert JP, Legido J, García-Sanz I, Pajares JM. Helicobacter pylori and perforated peptic ulcer prevalence of the infection and role of non-steroidal anti-inflammatory drugs. Dig Liver Dis. 2004; 36: 116-120.
  7. Bucher P, Oulhaci W, Morel P, et al. Results of conservative treatment for perforated gastroduodenal ulcer in patients not eligible for surgical repair. Swiss Med Wkly. 2007;137: 337-340.
  8. Boey J, Choi SK, Poon A, Alagaratnam TT. Risk stratification in perforated duodenal ulcers. A prospective validation of predictive factors. Ann Surg. 2001; 205: 22-26.
  9. Soreide J, Thorsen K, Harrison EM, et al. Perforated peptic ulcer. Lancet. 2015 Sep; 386(10000):1288-1298
  10. Fakhry S, Watts D, Daley B, et al. The EAST Multi-Institutional HVI Research Group: Current diagnostic approaches lack sensitivity in the diagnosis of perforating blunt small bowel injury (SBI): findings from a large multi-institutional study. J Trauma. 2001; 51: 1232.
  11. Gu WJ, Wang F, Bakker J, et al. The effect of goal-directed therapy on mortality in patients with sepsis - earlier is better: a meta-analysis of randomized controlled trials. Crit Care. 2014;18(5):570.
  12. Furukawa A, Sakoda M, Yamasaki M, et al. Gastrointestinal tract perforation: CT diagnosis of presence, site, and cause. Abdom Imaging. 2005;30(5):524–34.
  13. Ghekiere O, Lesnik A, Hoa D, et al. Value of computed tomography in the diagnosis of the cause of nontraumatic gastrointestinal tract perforation. J Comput Assist Tomogr. 2007;31(2):169–76.
  14. Di Saverio S, Bassi M, Smerieri N, et al. Diagnosis and treatment of perforated or bleeding peptic ulcers: 2013 WSES position paper. World Journal of Emergency Surgery. 2014;9:45

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Last updated: 2018-06-21 23:36