Excessive gastric acid secretion is only one factor in the pathogenesis of peptic ulcer disease. Perforated peptic ulcer ppu is relatively rare, but lifethreatening with the mortality varying from 10% to 40% 2, 46. Gastric and duodenal ulcers are both types of peptic ulcers. The management of large perforations of duodenal ulcers. Every year peptic ulcer disease pud affects 4 milion people around the world. We report the case of a 50yearold male smoker who presented in the emergency unit with acute generalized abdominal pain and guarding in the epigastric and right upper quadrant region. This protocol may be used by general practitioners, family doctors, and nurses. Indications for surgery in patients with peptic ulcer disease the indications for surgery for pud have recently been limited to the treatment of complicated pud.
Pdf management of perforated duodenal ulcer in a resource poor. Nonoperative management of perforated duodenal ulcer. A scarcity of highquality studies about the condition limits the knowledge base for clinical decision making, but a few published randomised trials are available. The management of perforated gastric ulcers sciencedirect. In patients with perforated peptic ulcer, what is the role of damage control surgery. Peptic ulceration occurs due to acid peptic damage to the gastro duodenal mucosa, resulting in mucosal erosion that exposes the underlying tissues to the digestive action of gastro duodenal secretions.
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. Ulcer formation is caused by infection with helicobacter pylori. A duodenal ulcer is usually caused by an infection with a germ bacterium called helicobacter pylori h. Perforated gastric and duodenal ulcers pgdu continue to be one of surgical problems accompanied by a 30% mortality rate and complications up to 50% including an acute abdominal syndrome, limited or generalized peritonitis and a high risk of sepsis. David is a 45yearold man, husband, and father of three. Surgical therapeutic management of perforated peptic ulcer.
Hostile factors no gastric acid, no peptic ulcer is a misconception. Genetic factors play a role in the pathogenesis of ulcer disease. Acute perforations of the duodenum are estimated to occur in 210% of patients. Pdf the majority of literature on the management of perforated duodenal ulcer comes from the west. Management of duodenal ulcer had changed after the discovery of h. A peptic ulcer on the inside of the stomach lining is a gastric. In patients with bleeding peptic ulcer, which are the. We present two cases of a perforated duodenal ulcer following rouxeny gastric bypass and discuss the management of these patients. The great debates of earlier in the century regarding simple patch closure versus immediate definitive surgery have been complicated by the arguments for and against laparotomy, the introduction of. Helicobacter pylori duodenal colonization is a strong risk factor for the development of duodenal ulcer. The ulcer may be referred to as duodenal, gastric, or esophageal, depending on its location.
An intraabdominal abscess developed in 1 of the 35 patients. Perforation complicates duodenal ulcer about half as often as bleeding and most perforated ulcers are on the anterior surface of the duodenum. However, these same symptoms are also seen in of patients with nonulcer dyspepsia. Ulcer pain may not correlate with the presence or severity of ulceration. Perforated duodenal ulcer is one of the most common causes of abdominal peritonitis. The cause of the duodenal ulcer is due to the infection by a bacteria called the helicobacter h. Other factors predisposing a person to ulcers include antiinflammatory medications and cigarette smoking. Management of perforated gastric and duodenal ulcers. Treatment goals in the acute setting are the relief of discomfort and protection of the gastric mucosal barrier to promote healing. A clinical case study duodenal ulcer perforation is the second most common abdominal emergency in our study.
Surgical repair of perforated gastroduodenal ulcer has been extensively practiced in emergency clinical situations. Protocol for diagnosis and treatment of peptic ulcer in adults. For a couple of weeks, he has been feeling a slight pain in his stomach, which he thought was just heart burn. Background 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. Normally, the lining of the stomach and small intestines can protect itself against strong stomach acids. The ulcer was believed to be acute in 27 patients and chronic in 8. A crater ulcer in the lining of the beginning of the small intestine duodenum. Perforated peptic ulcer is a common emergency condition worldwide, with associated mortality rates of up to 30%. Gastric and duodenal ulcers are types of peptic ulcer. A noninvasive 24 hours stabilization of duodenal ulcer. Pdf diagnosis and management of duodenal perforations. The lifetime prevalence of developing ulcer disease in firstdegree relatives of ulcer patients is about three times greater than the general population. Perforated and bleeding peptic ulcer clinical practice. Peptic ulcers are sores that develop in the lining of the stomach, lower esophagus, or small intestine.
The ulcer that develops on the uppermost portion of the small intestine and also on the inside lining of your stomach is known as the peptic ulcer. The earliest operative description was made by mikulicz in 1884 but the first successful operation for a perforated duodenal ulcer was not until 1894 over the last two decades there have been a number of advances in the management of perforated duodenal ulcer. Decreased mucosal defense against gastric acid is another cause. In the emergency treatment of a perforated duodenal ulcer du, after surgical closure of the perforation and treatment of the secondary peritonitis, higly selective vagotomyhsv is a valid therapy to prevent recurrence of the underlying. Peptic ulcer disease is common with a lifetime prevalence in the general population of 510% and an incidence of 0. Perforated ulcers of the upper gastrointestinal tract are potentially complicated surgical emergencies. Current concepts in management of the perforated peptic ulcer. Noninvasive conservation treatment is regaining the attention towards management of such ulcers. Peptic ulcer disease is a leading cause of duodenal perforation. Vagotomy and emptying procedure in treatment of acute perforated duodenal ulcer arch.
Berne cjrosoff sr lrnyhus lmedwastell ced acute perforation of peptic ulcer. Peptic ulcer disease pud results from an imbalance between stomach acidpepsin and mucosal defense barriers. A healthy diet for duodenal ulcer has low salt, bad fat content and sugar. All of the patients were under the age of 60 years and presented with stable vital signs. Ppu presents as an acute abdominal condition, with. A peptic ulcer is an open sore or raw area in the lining of the stomach or intestine.
Strategies to improve the outcome of emergency surgery for. These ulcers can cause different symptoms, depending on where they are. However, complications related to peptic ulcer disease continue to occur and include bleeding, perforation, and gastric outlet obstruction. Management of perforated duodenal ulcer surgical treatment. Surgical management of peptic ulcer disease uptodate. There are a host of healthy food items for a patient suffering from duodenal ulcer. Highly selective vagotomy in the management of perforated duodenal ulcer. The traditional management of a perforated duodenal ulcer has been a graham omental patch and a thorough abdominal lavage. In 2020, the world society of emergency surgery wses released guidelines for management of perforated and bleeding peptic ulcers.
The incidence of pud has been estimated at around 1. To evaluate the pattern of presentation and mode of management of duodenal ulcer perforations. An alternative plan for the treatment of a perforated duodenal ulcer is proposed. 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. Protocol for diagnosis and treatment of peptic ulcer in. The present management of perforated duodenal ulcer is in flux. Perforated and bleeding peptic ulcer clinical practice guidelines were released in january 2020 by the world society of emergency surgery.
If laparotomy is undertaken and a straightforward duodenal ulcer encountered, closure with an omental patch is wellestablished as the optimal procedure. Diagnosis and treatment of peptic ulcer disease and h. Peptic ulcer is an ulceration in the mucosal wall of the lower esophagus, stomach, pylorus, or duodenum. Perforation is one of the most catastrophic complications of peptic ulcer.
Complications are encountered in 10%20% of these patients and 2%14% of the ulcers will perforate 2, 3. They affect different parts of the digestive tract, but both can cause pain and discomfort, and serious complications if. Prognosis and treatment of acute perforated ulcer lancet 264. Surgical management of peptic ulcer disease todayindication, technique and outcome. A 4 to 8week course of acidsuppressing medication will allow the ulcer to heal. These 35 cases represent 12% of 294 cases of duodenal and prepyloric peptic ulcers with perforation treated during the same period. While treatment for stable duodenal ulcer is done with medication, bleeding ulcer calls for endoscopic therapy, while a perforated ulcer is treated with surgery. Approximately 2050% of duodenal ulcer patients report a positive family history. Pdf surgical management of perforated peptic ulcer disease.
Duodenal ulcer treatment varies from one patient to another, depending upon disease etiology and severity of the condition. After invention of the h2 blockers and proton pump inhibitors the role of elective surgery for duodenal ulcer has been drastically decreasing, but the incidence of perforation is not much changing. Surgical treatment of perforated peptic ulcer medscape emedicine. The recommended biochemical and imaging investigations in the diagnosis of perforated peptic ulcer are as follows. 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. When is surgical management of peptic ulcer disease pud. The most common symptom of both gastric and duodenal ulcers is epigastric pain. The first report of a series of patients presenting with perforation of a duodenal ulcer was made in 1817 by travers. It is estimated that 2% to 10% of patients with gastric or duodenal peptic ulcer perforation shall in the course of his life, being disproportionately greater mortality. Discussion duodenum is the second most common location to be affected by diverticula, after the colon. The healthy diet for duodenal ulcer patients include fruits, veggies, grains, fat free dairy products, pasta, whole wheat bread, cereals, brown rice, beans, eggs, lean meats, fish, eggs, and poultry. Background perforated peptic ulcer ppu is a common surgical. Diagnosis and management of perforated duodenal ulcers.
Theyre usually formed as a result of inflammation caused by the bacteria h. The most discriminating symptom of pain awakening the patient from sleep between 123 a. 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. We will focus on the nowrecognized role of helicobacter pylori in the genesis of the majority of duodenal ulcers and on the high rate of success of therapy with a combination of antibiotics and a protonpump inhibitor or histamine 2 blocker in treatment of such ulcers. The role of endoscopy in the management of patients with.
Although helicobacter pylori and use of nonsteroidal antiinflammatory drugs are common causes, demographic. More than half of the cases are female and they are usually older and. N engl j med 1989 apr emergency surgery is generally considered the treatment of choice for perforated peptic ulcer, even though some perforations seal rapidly and do not require surgery. Diagnosis and treatment of perforated or bleeding peptic. Pdf the management of large perforations of duodenal ulcers. The classic triad of sudden onset of abdominal pain, tachycardia and. Duodenal ulcer occurs in the first part of the small intestine.
We describe the selective nonoperative management of 34 patients who had an initial diagnosis of perforated duodenal ulcer made on acute presentation between 19841994 in our. Nonoperative treatment of perforated duodenal ulcer jama. Twelve years progress in surgery for perforated gastric and duodenal ulcers. Pdf surgery for perforated peptic ulcer disease is one of the most common emergency procedures carried out in the western world. Presentation and management of perforated duodenal ulcer. Presentations of peptic ulcer disease and gastritis usually are indistinguishable in the emergency department ed and, thus, the management is generally the same. In addition, a oneweek course of two antibiotics plus an acidsuppressing medicine will usually clear the h. Introduction perforated peptic ulcer is a surgical emergency and is associated with shortterm mortality in up to 30% of patients and morbidity in up to 50%.1117 963 547 1004 1038 269 412 922 879 895 1470 272 311 608 1555 1382 448 497 1223 1110 850 489 953 1146 583 16 743 220 268 894 1389