Recurrent Peptic Ulcer Perforation: A Case Report

Background: Refractory peptic ulcers are ulcers in the stomach or duodenum that do not heal after eight to twelve weeks of medical/surgical treatment or those that are associated with complications despite medical tssreatment. We herein present a case of a 44 year old man with a recurrent perforated duodenal ulcer requiring emergent surgical intervention.

Hepatic portal vein gas in gastric outlet obstruction

A 55-year-old man presented to an emergency department with a history of abdominal pain and vomiting for one week. He had a history of having peptic ulcer perforation surgery. He appeared weak and frustration from pain, abdominal distension at upper abdomen without peritonitis sign on physical examination. Initial abdominal radiograph revealed pneumoperitoneum under both hemidiaphragms with markedly distension of stomach containing food content. Further computed tomography demonstrated evidence of gastric outlet obstruction without intra or extraluminal mass. There is also massive amount of portal venous gas in both lobes of liver. After patient resuscitation with intravenous fluid and nasogastric intubation for gastric decompression, his condition returned to normal, with no sign of peritonitis nor sepsis. Therefore, the upper gastrointestinal endoscopy showed gastric outlet obstruction from chronic peptic ulcers. The endoscopic balloon dilatation of the obstruction part was successful, and he was discharged home with full recovery in one week.

THE COMPARATIVE STUDY BETWEEN OPEN TECHNIQUES VERSUS LIMBERG FLAP TECHNIQUE IN MANAGEMENT OF SACROCOCCYGEAL PILONIDAL SINUS

Background: Comparative study of laparoscopic and open surgical method in management of peptic ulcer perforation Methods: The present study was conducted in patients presented with perforation peritonitis to the emergency department in G.G.S medical college and hospital, a tertiary care hospital in Faridkot, Punjab in which comparison of the clinical outcome between laparoscopic and open surgical methods for treatment of Gastro duodenal perforation was study. Results: Mean operative time of laparoscopic repair group was higher (158.2±0.64 min) in comparison to open repair group (70.8±0.42 min). In the present study post-operative pain score was assessed in each and every patient using Visual analogue scale. On post-operative day 1, mean VAS for OR Group was significantly higher in comparison to LR Group. Later on postoperative day 3, Majority of patients of in LR group had a highest score of 1-4 while in OR group was score 5-7.Nexton postoperative day 5, again mean VAS for LR patients was less in comparison to OR Group. Conclusion: As this is the first kind of study in our geographical area in which role of alcohol proved to be an important risk factor. Laparoscopic approach for repair of perforated peptic ulcer may offer significant advantage over open repair approach with lesser post-operative pain, lsser postoperative complications like wound infections, comparable reperforation rates and lesser duration of hospital stay. Keywords: Laparoscopic, Open, Repair

COMPARATIVE STUDY OF LAPAROSCOPIC AND OPEN SURGICAL METHOD IN MANAGEMENT OF PEPTIC ULCER PERFORATION

Background: Comparative study of laparoscopic and open surgical method in management of peptic ulcer perforation Methods: The present study was conducted in patients presented with perforation peritonitis to the emergency department in G.G.S medical college and hospital, a tertiary care hospital in Faridkot, Punjab in which comparison of the clinical outcome between laparoscopic and open surgical methods for treatment of Gastro duodenal perforation was study. Results: Mean operative time of laparoscopic repair group was higher (158.2±0.64 min) in comparison to open repair group (70.8±0.42 min). In the present study post-operative pain score was assessed in each and every patient using Visual analogue scale. On post-operative day 1, mean VAS for OR Group was significantly higher in comparison to LR Group. Later on postoperative day 3, Majority of patients of in LR group had a highest score of 1-4 while in OR group was score 5-7.Nexton postoperative day 5, again mean VAS for LR patients was less in comparison to OR Group. Conclusion: As this is the first kind of study in our geographical area in which role of alcohol proved to be an important risk factor. Laparoscopic approach for repair of perforated peptic ulcer may offer significant advantage over open repair approach with lesser post-operative pain, lsser postoperative complications like wound infections, comparable reperforation rates and lesser duration of hospital stay. Keywords: Laparoscopic, Open, Repair

794 Diagnostic Pitfall in Atypical Presentation of Malignant Gastric Ulcer Perforation

Background Peptic ulcer perforation is one of the most common surgical problems in daily practice. Although it can be easily diagnosed clinically, the clinical presentation can be less obvious in some cases leading to diagnostic pitfalls and mortality. This case report aims to highlight an atypical presentation of malignant gastric ulcer perforation in a patient with chronic abdominal pain. Case presentation A 78-year-old lady presented with chronic abdominal pain for 3 months. Investigations and imaging revealed T2N1M0 malignant gastric ulcer which was confirmed by endoscopy. Due to her low body mass index and underlying comorbidities, she was admitted for pre-operative optimization. However, she was a good 78 with the clinical frailty scale 4 and the National Early Warning Score 0 throughout the stay. On the night before the operation, she suddenly developed delirium. Further history revealed marked oliguria for 12 hours. There was mild abdominal distension without peritonism. She was catheterized and treated with fluids and antibiotics. X-ray suggested massive pneumoperitonium. Subsequently, she developed full-blown septic shock with rapid clinical deterioration within 3 hours. With the estimated Boey scoring of 3 and rapid clinical deterioration, the symptom control approach was decided. A palliative bedside ascitic tap was performed to relieve the discomfort. Four hours after the onset, unfortunately, the patient passed away. Conclusions Although gastric ulcer perforation usually presents with obvious symptoms, extra precaution should be exercised in elderly patients with chronic abdominal pain and comorbidities. We could learn that routine monitoring of urine output might aid in the early diagnosis of sepsis.

Peptic Ulcer Perforation: An Enigma Since Antiquity

Peptic ulcer disease (PUD) is a serious medical condition. The perforation of peptic ulcers (PPU) causes a steep rise in mortality and morbidity. It accounts for 70% of deaths associated with PUD. More than 60% of perforations occur in the anterior wall of the duodenum, while 20% of it is in the antrum. The gastric ulcer perforation contributes to approximately 20% and is in lesser curvature. The risk factor includes non-steroidal anti-inflammatory drugs (NSAID), Helicobactor pylori (H. Pylori), smoking, alcoholism, Corticosteroid, and stress are some of the risk factors. There is a change in the epidemiology of PUD recently. The improvement is remarkable and is due to improved socio-economic status, identification and treatment of Helicobacter pylori, and introduction of proton pump inhibitors. The H pylori infection remains one of the most important causes of PUD and its complications like PPU. The reason for reviewing and writing this paper is to evaluate the most common ideas on the treatment of peptic ulcer perforation, opinion on conservative treatment, and surgical treatment options.

Seasonal Pattern of Peptic Ulcer Perforation in Central Anatolia

BACKGROUND Previous studies have reported seasonal variations in peptic ulcer disease (PUD), but only few large-scale, population-based studies have been conducted in this regard. In this study, we wanted to present the seasonal relationship of peptic ulcer perforation admissions, seasonal variation of its incidence, modes of surgical management, the seasonal distribution of postoperative severe complications and the patient outcome. METHODS This is a retrospective cohort study. Patients hospitalized for peptic ulcer perforation between 1st January 2008 and 1st January 2020 were included in the study. The patients were divided into two groups according to postoperative complication status as Group1 - Clavien Dindo < 3 and Group 2 - Clavien Dindo > 3. Age, gender and seasonal periods were compared. In addition, patients were divided into three groups according to age as 18 – 40 yrs., 40 - 60 yrs. and over 60 yrs. The gender and complication status of the patients were also evaluated in seasonal groups. RESULTS 135 patients participated in our study. Group 1 constituted of 107 patients and Group 2 constituted of 28 patients. Admission to the hospital due to peptic ulcer perforation was most common in spring (29.6 %) and summer (29.6 %). Twenty - eight patients had Clavien - Dindo 3 or more complications. The mean age was higher in Group 2 (70.78 vs 50.2 P : 0.001) as well as female gender dominancy (60.7 % vs 29.9 %). In Group 2 winter months were more frequent (46,5 % vs 21.5 %); however, there was no significant difference between the seasons and the complication groups. In Group 2, female gender was more common in winter (21.7 % vs 69.2 % P:0.005) and autumn season (31.3 % vs 100 % P : 0.027). CONCLUSIONS In our study, we found an increased incidence of peptic ulcer perforation in spring and summer. For patients at higher risk, an appropriate pharmacological treatment can be arranged to reduce the risk of perforation during the risky season. KEY WORDS Peptic Ulcer Disease, Seasonal Change, Complication

STUDY OF INCIDENCE OF PEPTIC ULCER PERFORATION IN YOUNG ADULTS

BACKGROUND: Peptic ulcer formation affects about 2-10% of world population every year with higher incidence in younger individuals. Being a surgical emergency, it has higher mortality and morbidity. Thus the aim of our study was to evaluate the incidence of peptic ulcer perforation based on gender age and also to study its associated risk factors, clinical presentations, site along with surgical management and complications

Clinical Presentation and Management of Patients with Peptic Ulcer Perforation in Kashmir - A Prospective Study

BACKGROUND Around 4 million people are affected by peptic ulcer diseases worldwide annually. The incidence of around 1.5 % to 3 % has been estimated. Peptic ulcer perforation presents with an overall mortality of 10 %. The management is also associated with significant post-operative morbidity and mortality regardless of whether laparoscopic or open repair is performed. In this study, we wanted to find out the incidence of peptic ulcer perforation and its management. METHODS Our study was a prospective observational study conducted in post graduate Department of Surgery, Government Medical College Srinagar, from October 2018 to November 2020. All patients were evaluated properly with all baseline investigations followed by X-ray chest and abdomen and ultrasonography (USG). RESULTS In our study, 136 patients were diagnosed as cases of peptic ulcer perforation. The maximum number of patients were in age group of 41 - 50 years (27.20 %). The male : female ratio was 14.1 : 1. Abdominal pain was present in all patients as presenting symptom followed by abdominal distension. In this study, 124 patients (91.2 %) had perforation in first part of duodenum, 9 patients (6.6 %) had perforation in prepyloric region and 3 (2.2 %) patients had perforation in body of stomach. Graham’s Patch repair was done in 133 patients, 1 patient underwent primary closure, and 2 patients underwent distal gastrectomy with gastrojejunostomy. CONCLUSIONS Our study shows that young people with perforated peptic ulcer have fewer coexisting medical illness, a lower complication rate and a more favorable outcome as compared to elderly patients with perforated peptic ulcer. A majority of such perforations are in 1st part of duodenum with male preponderance. A plain chest radiograph is sufficient to make diagnosis in the classic case of sudden onset epigastric pain. KEYWORDS Perforation Peritonitis, Management of Peptic Ulcer Perforation, Graham’s Repair, Clinical Presentation of Peptic Ulcer Perforation