PERFORATED PEPTIC ULCER DISEASE: THE BAYELSA STATE EXPERIENCE.
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PERFORATED PEPTIC ULCER DISEASE: THE BAYELSA STATE EXPERIENCE. NIGER DELTA MEDICAL JOURNAL
PERFORATED PEPTIC ULCER DISEASE: THE BAYELSA STATE
EXPERIENCE.
1
Dr Benjamin I. Tabowei , FMCS.
Dr Oyintonbra F. Koroye1, FWACS, FICS, FACS.
1
Dr Hudson Sam Ukoima , FMCS.
1
Department of Surgery, Niger Delta University Teaching Hospital,
Okolobiri. Bayelsa State, Nigeria
Correspondence to:
Oyintonbra F. Koroye,
Department of Surgery,
Niger Delta University Teaching Hospital,
Okolobiri. Bayelsa State, Nigeria
Email address: oyintonbrak@yahoo.com
ORCID ID; 0000-0002-0928-1748
ABSTRACT
Peptic ulcer disease (PUD) is a chronic condition affecting mankind. Perforation of a peptic ulcer is one of
the most common complications of this disease. Perforated peptic ulcer is a common cause of the acute
abdomen, requiring urgent surgical intervention. The aim of the paper is to determine the pattern of
perforated peptic ulcer in our hospital. The specific objectives are to determine the risk factors, clinical
presentation and the treatment outcomes in these patients. All patients who had surgery for acute abdomen
with a finding of perforated duodenal or gastric ulcer from 2012 to 2017were included in this retrospective
study. Variables analysed were the biodata, risk factors, clinical features, chest xray findings, duration of
symptoms, type of surgery done and complications. There were fifty patients meeting the inclusion criteria.
There were 28 males and 22 females. The 41 to 50 age group was the most affected. The use of Non-Steroidal
Anti-Inflammatory Drugs (NSAIDs) and alcohol consumption were seen in 30% and 76% of patients
respectively. Ninety percent had an abdominal massage, an unorthodox practice in our environment, after
the onset of symptoms but before presentation in hospital. Ninety six percent of our patients presented after
24 hours of the onset of symptoms. Severe abdominal pain was present in all our patients. All patients were
treated surgically with simple closure reinforced with a Graham's patch and lavage with warm saline.
Wound infection was the commonest complication post operatively. The mortality rate was 40%. Late
presentarion and a high mortalty rate was seen in our series. Mass education on the dangers of procuring
NSAIDs and other drugs procured over the counter without a doctor's prescription should be embarked on.
The importance of early health seeking behaviour should also be stressed.
KEY WORDS; perforated peptic ulcer disease, duodenal and gastric perforation, Bayelsa State,
Nigeria,
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INTRODUCTION. of perforation may be insidious or equivocal.
Peptic ulcer disease (PUD) is a common A study from Benin city, Nigeria, had reported
chronicgastrintestinal condition affecting some risk factors implicated in
human populations.1 Before the establishment 15
perforatedpeptic ulcer . These include;
of the causal relationship between H.Pylori and alcoholconsumption, smoking, and the intake
2
peptic ulcerby Warren and Marshal, the of non-steroidal anti-inflammatory drugs
definitive treatment of this disease was (NSAIDS) such as ibuprofen and diclofenac. In
3
surgical. Currently, the cure for peptic ulcer recent years, Helicobacter pylori infection and
disease is from the use of the H-pylori ingestion of NSAIDs have been identified as
eradication regimen which was first patented the two main causes of peptic ulcer
4
in 1984 by Thomas Borody. Nowadays elective perforation.16 Others had also observed that
surgery for PUD has virtually disappeared.3 the use of cracked cocaine leads to increased
Surgery is now almost exclusively reserved for incidence of perforation in patients with peptic
some of the complications of PUD which ulcer disease.17
include perforation, bleeding and gastric outlet
obstruction.3,5 Perforated peptic ulcer is one of The diagnosis of peptic ulcer perforation is
6
the commonest causes of the acute abdomen. usually made from the history, clinical
Despite the improvement in medical practices examination and in 75% of cases, an erect chest
and technology, perforations of peptic ulcers X-ray radiography showing air under the
18
still pose a challenge to the clinician especially diaphragm . However, recently computerized
in the third world.7 as between 2-14 percent of tomographic scan is the gold standard for
patients who have peptic ulcer disease develop detecting and making a diagnosis of a
this complication.6,8 As was noted by other perforated peptic ulcer.
19
colleagues9,10,11, perforation may be the first Delay before surgical treatment is instituted,
clinical presentation of peptic ulcer disease in amongst other factors,isa strong determinant
some patientsespecially in developing for increased complicationrates, hospital cost
countries. and mortality20.
The perforation results in spillage of The mainstay of treatment of perforated peptic
gastric/duodenal contents into the free ulcer is usually surgical after adequately
21
peritoneal cavity with resultant chemical resuscitating the patient. Conservative
peritonitis and later, purulent infection.''12 treatment consisting of nasogastric aspiration,
Hirschowit et al 13reported that two thirds of antibiotics, intravenous fluid and nowadays
the patients with perforated gastric ulcer the use of proton pump inhibitors and
present with severe sudden pain that radiates eradication of Helicobacter pylori using the triple
to the back and with features of spreading therapyregime can be useful in few selected
22
peritonitis. Other experts also noted that cases.
patients with perforated peptic ulcer have a In developing countries, patients with
typical history of sudden onset of acute sharp perforated peptic ulcer disease often present
pain usually located in the epigastric region late to health facilities for manangement.10 This
with shoulder pain indicating free air under the has led to the high morbidity and mortality
diaphragm14. However, in the elderly or in observed in patients with perforated peptic
patients who are immunosuppressed, the signs ulcer disease in this environment. This study
Nig Del Med J 2021; 5(2): 25-33 Page 26PERFORATED PEPTIC ULCER DISEASE: THE BAYELSA STATE EXPERIENCE. NIGER DELTA MEDICAL JOURNAL
aims to determine the risk factors, clinical findings, complications seen, and the
presentation and the treatment outcomes of treatment outcome. Other variables analysed
patients with perforated peptic ulcer disease in includelength of hospital stay, morbidity and
our facility. mortality. Patents who had perforated
appendicitis, typhoid perforation and
PATIENTS AND METHODS. traumatic perforation of the gut were excluded
This is a descriptive retrospectivestudy carried from the study. Data obtained were analysed
out over a 5 year period at the Niger Delta using the SSPS 16 version package. Ethical
university Teaching Hospital (NDUTH) committee approval was sought and obtained
Okolobiri between June 2012 to July 2017. for the study.
NDUTH Okolobiri is a 200-bed capacity
tertiary Bayelsa State owned hospital. RESULTS.
Allconsecutive patients who had surgery for A total of 55 case notes of patients operated for
perforated peptic ulcer disease were obtained
acute abdomen with the confirmation of a
from the hospital database.Five cases were
duodenal or gastric perforation were included
excluded because of incomplete
in the study. The patients case notes, documentation. Of the 50 cases analysed,
anaesthetic notes and the nursing notes were 28(56%) were males and 22(44%) were females;
obtained, entered into a proforma and giving a male to female ratio of 1.3 to 1. Their
analysed. Data were analyzed for age, sex, ages ranged between 15 to 82 years, the mean
occupation, past history of pepetic ulcer age was 44 years ± 7. Majorityof the patients
disease, drug history, associated risk factors, (72%) had no previous history of peptic ulcer
disease.
clinical features, investigations done,
treatment given, type of surgery, operative
Table 1. The age and sex distribution of patients.
Number Males Female Percentage.
0-10 0 0 0 0
11-20 3 2 1 6
21-30 6 3 3 12
31-40 11 6 5 22
41-50 18 10 8 36
51-60 7 4 3 14
61-70 3 2 1 6
>70 2 1 1 4
Total 50 28 22 100
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Table 2. Occupation of patients.
Occupation of patients. Number Percentage
Farmers. 12 24
Civil servants 5 10
Unemployed 8 16
Fishermen 13 26
Business 6 12
Students 2 4
Others 4 8
Total. 50 100
Table 3. Interval between onset of symptoms and presentation at the hospital
Onset of Symptoms Number Percentage
0-24 hours 2 4
25-48 hours 7 14
49-60 hours 13 26
61-72 hours 20 40
>72 hours 8 16
Total 50 100
Table 4. Risk factors.
Risk factor Number Percentage
Alcohol 38 76
NSAIDs+ alcohol 42 84
NSAIDs Alone 15 30
Smoking, Alcohol, NSAIDs 30 60
Herbal concoction ingestion 7 14
Fasting 2 4
Massaging the abdomen 45 90
None 11 22
Table 5. Clinical features.
Clinical Feature Number of patients Percentage
Pain 50 100
Nausea 29 58
Vomiting 20 40
Fever 36 72
Constipation 5 10
Diarrhea 3 6
Abdomenal rigidity 50 100
Abdominal distension 38 76
Silent abdomen 43 86
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The most reliable investigation done to make a diagnosis of perforated peptic ulcer diseae was
erect plain abdominal X-Ray which showed air under the diaphragm in 45(90%) of patients, while
the ultrasound scan revealed free peritoneal fliud and debris in 46(92%)of the patients.
All the patients had surgery with simple closure of the perforation with omental patch. Irrigation
of the peritoneal cavity with warm normal saline and insertion of a tube drain was carried out in
all patients. No patient hadany definitive vagotomy and drainage procedures.
Table 6. Complications seen in our patients.
Type of complication Number Percentage
Wound infection 26 52
Burst abdomen 16 32
Septicemia. 18 36
Intra-abdominal abscesses 10 20
Prolong Ileus 24 48
Pneumonia 16 32
Electrolyte imbalance 18 36
Death 20 40
DISCUSSION. the use of NSAIDs are common among males
It is one of the commonest causes of surgical and females in our environment, not many
emergency and hospitalization. Despite the females smoke amongst our catchment
wide spread use of gastric antisecretory agents population. This may also account for the
and eradication therapy, the incidence of slight differences in incidence in the ratio
peforated peptic ulcer has changed little.
23 between male and females who have
perforation of peptic ulcer in our series.
Perforated peptic ulcer used to be a disorder
mainly of younger patients (predominantly Although, perforation of a peptic ulcer cuts
males), but recently, studies have shown that across all strata of human populations, 50% of
the age of patients with perforated peptic ulcer our patients were fishermen and farmers and
disease is increasing and many more females are assumed to be of low socio-economic class
are being affected.24 Others had noted that as these activities are done in a small scale in
perfortated peptic ulcer disease occur most this semi-urban environment. This observation
commonly in the fourth decade of life and that is consistent with those reported by Dongo et
it affects more males than females25. Males and aland other workers who observed this
females were almost equally affected in the complication affected people of a kower
ratio of 1.3:1 by the disease. This is in sharp socioeconomic status.''12
contrast with the report of other authors who
Typically, patients with peptic ulcer disease
had documented that males predominated in
present with a sudden onset of severe, sharp
the number of patients that had perforation of
peptic ulcer disease.
23,24,25
Smoking, the use of pain usually located in the epigastric area and
14
alcohol and ulcerogenic drugs such as NSAID sometimes with pain under the shoulder . In
shave been implicated in causing peptic ulcer our study, all(100%) of our patients had severe
26
perforation as documented by others . While abdominal pains at presentation, similar to
27,28
risk factors such as alcohol consumption and those reported in the literature .
Nig Del Med J 2021; 5(2): 25-33 Page 29PERFORATED PEPTIC ULCER DISEASE: THE BAYELSA STATE EXPERIENCE. NIGER DELTA MEDICAL JOURNAL
The diagnosis of peptic ulcer diseasein many peptic ulcer as was noted in our study, it is
developing countries is first made following a necessary to educate and sensitise patients on
11
perforation .In our study, 36(72%) of the the etio-pathology and complications of peptic
patients had no previous history suggestive of ulcer disease and the need to present to health
peptic ulcer disease, similar to that reported in facilities as soon as symptoms of abdominal
the literature1,10,11,25. pain begin.
In ourseries, 72% had no previous history of Non-operative treatment in the form of
peptic ulcer disease. The reasons cannot be intravenous fluids, nasogastric tube suction,
accurately inferred as this was a retrospective intravenous antibiotics and the use of proton
study. inhibitors is safe and effective in selected cases
Others had noted that in developing countries as perforations frequently get sealed off
such as Nigeria, patients with perforated spontaneously by omentum and adjacent
peptic ulcer present late to health facilities10.In organs32.
Port Harcourt which is 80km from our center,a
studyshowed that 88.9% of the patients In our series, most of the patients presented
presented late to the hospital. In our series, 96% late, some were in a state of shock and their vital
of the patients presented late to health facilities signs were unstable. They were actively
after pepetic ulcer perforation., comparable to resuscitated with fluids, antibiotics, analgesics,
those reported elsewhere10,15,25,29. and therefore none was offered the
conservative or non operative mode of
Ignorance, religious beliefs, lack of easy treatment. Intraoperatively, only four(8%)
assessibility to health facilities, use of patients had their perforation sealed off by
alternative/ traditional medicine practitioners omentum and surrounding organs. Although,
and charlartans, poverty and the high cost of conservative management in few selected cases
treatment are contributory factors. may be beneficial, in our environment, this may
The presence of air under the Diaphragm in an be fraught with difficulties due to inadequate
erect position is diagnostic of perforated peptic intensive care facilities. Most of our patients do
ulcer18. In our study, air under the diaphragm not meet the criteria for conservative
was seen in 92% of the cases. management due to complications associated
Delay before surgical treatment is a strong with late presentation for specialist care. It is
determinant for increased complication rates, our opinion therefore, that the open operative
hospital costs and mortality rates20. Shock on management of the patients be adopted in this
admission, associated pre-existing medical environment as soon as the diagnosis of
illness and prolonged perforation has been perforation of the peptic ulcer is made.
shown to be a useful tool in predicting outcome
in patients with perforated peptic ulcer Closure of the perforation with omental
22,31
disease . patch(Graham's procedure) and the use of
proton pump inhibitors and antibiotics for the
The high mortality rate (40%)was due to delay eradication of Helicobacter Pyloriis now the
in instituting medical/surgical treatment as standard of care,5. In our series, simple closure
most of the patients presented late to the health with omental patch and copious irrigation of
facilities. To decrease the high morbidity and the peritonel cavity with warm normal saline
mortality associated with perforation of the was carried out in all the cases. Tube drains
Nig Del Med J 2021; 5(2): 25-33 Page 30PERFORATED PEPTIC ULCER DISEASE: THE BAYELSA STATE EXPERIENCE. NIGER DELTA MEDICAL JOURNAL
were inserted at both the left and right 3. Paimela H, Oksala NKJ, Kivilaakso E.
paracolic gutters. No patient had the Surgery for peptic ulcer today: A
traditional definitive vagotomy and drainage study on the incidence, methods and
procedure done but all had proton-pump mortality in surgery for peptic ulcer
inhibitors and antibiotics to eradicate in Finland between 1987 and 1999.
Helicobacter pylori. Dig Surg. 2004;21(3):185-191.
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11,12,15,29
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