Experience with acute perforated duodenal ulcer in a West African population

The advent of proton pump inhibitors and helicobacter pylori eradication in the management of chronic peptic ulcer disease has reduced the operative treatment of this condition to its complications. Perforated duodenal ulcer remains a major life threatening complication of chronic peptic ulcer disease. This retrospective study reviews our experience at the Royal Victoria Teaching Hospital.

All patients with clinical diagnosis of perforated duodenal ulcer seen in this hospital between June 2003 and October 2005 were included in this study. Data extracted from their hospital records were analyzed for age, sex, duration of symptoms, previous history of peptic ulcer disease, use of NSAIDS, main presenting features, investigations, resuscitative measures, time of surgery, operative findings, and type of surgery offered, complications and mortality. After resuscitation, laparotomy followed by simple closure or definitive ulcer surgery and helicobacter pylori eradication therapy was given to all the patients. Duration of follow up ranged 8 to 12 months with endoscopy in some patients.

There were 41 patients with intraoperative diagnosis of acute perforated duodenal ulcer seen over the study period, comprising 34 males (82.9%) and 7 females (17.1%), a male female ratio of 4.8:1, age range of 18-77 years and a mean age of 45.49 +/- 14.46 years. Previous history of peptic ulcer disease was found in 32 (78.6%) of the patient and the main presenting features were sudden onset of severe abdominal pain in 95.1% of cases and fever in 65.8%. Features of frank peritonitis were demonstrable in all the patients and 11 (26.8%) presented in shock. Plain chest x-rays demonstrated gas under the diaphragm in 21(65.6%) of the patients. After adequate resuscitation, all the patients underwent laparotomy where the abdomen was explored, the diagnosis of perforated duodenal ulcer was confirmed and 29 (70.7%) had simple closure of the perforation with omentum (after Graham). The average time between presentation and surgery was 9 hours (range 6-11 hours). The mean size of perforation was 10.5 mm (range 5-15 mm). Definitive peptic ulcer surgery was done in 12 (29.3%) patients. 8 had truncal vagotomy and pyloroplasty. The major complications included wound infection in 14 (34.1%), postoperative fever in 16 (39.0%) and prolonged ileus in 15 (36.6%) There were 7 deaths, mortality rate of 17.1% and the causes of death included severe electrolyte imbalance in 1 and gram negative septicaemia and shock in 6. The average duration of hospital stay was 10 days (range 8-36).

Perforated duodenal ulcer is a major complication of chronic peptic ulcer disease. Simple omental patch by open method and helicobacter pylori eradication therapy is sufficient to prevent reperforation.