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Unsuspected perforation in bleeding duodenal ulcers
K S Dasmahapatra1, W Suval, G W Machiedo
1Surgical Service, VA Medical Center, East Orange, New Jersey 07019.
Insights
Simultaneous bleeding and perforation in peptic ulcer disease is rare but significantly increases operative mortality. Unsuspected perforations in bleeding patients can delay diagnosis and treatment, highlighting the need for vigilance.
Area of Science:
- Gastroenterology
- Surgical Gastroenterology
- Clinical Medicine
Background:
- Peptic ulcer disease (PUD) complications, bleeding and perforation, rarely occur together.
- Simultaneous presentation of bleeding and perforation in PUD poses diagnostic and therapeutic challenges.
Purpose of the Study:
- To investigate the incidence and impact of unsuspected duodenal ulcer perforation in patients presenting with bleeding.
- To compare operative mortality rates between patients with isolated bleeding, isolated perforation, and combined bleeding and perforation.
Main Methods:
- Retrospective review of 127 patients who underwent surgery for peptic ulcer bleeding or perforation.
- Analysis of patient demographics, clinical presentation, operative findings, and outcomes, including mortality.
Main Results:
- 9.9% of patients with bleeding peptic ulcers had unsuspected perforations.
- Operative mortality was significantly higher in combined bleeding and perforation (44%) compared to bleeding alone (9.8%) or perforation alone (11.0%).
- Nonsurvivors were older and had a longer duration of symptoms, with preoperative fever, leukocytosis, and tachycardia being common in non-survivors.
Conclusions:
- Perforation is an under-recognized complication in patients with bleeding peptic ulcers.
- Clinical signs of perforation may be masked by bleeding, leading to delayed surgical intervention and increased mortality.
- Fever, leukocytosis, and tachycardia in bleeding peptic ulcer patients warrant suspicion for concurrent perforation.
Abstract:
A combination of bleeding and perforation rarely occurs simultaneously in peptic ulcer disease. The charts of 127 patients undergoing surgery for either complication were reviewed (bleeding, 91; perforation, 36). Nine of 91 (9.9%) patients in the bleeding group were found at operation to have a unsuspected perforated duodenal ulcer. The operative mortality in the patients with the combined complications (44%, 4/9) was significantly higher than that in patients with bleeding alone (8/82, 9.8, P less than 0.001) or those with perforation alone (4/36, 11.00, P less than 0.025). The mean age of nonsurvivors was significantly higher than that of the survivors (74 +/- 8.01 vs 50.4 +/- 5.65 years, P less than 0.005). The duration of symptoms until operation was longer in patients who died (63 +/- 12.7 hours) than in survivors (40.2 +/- 6.02 hours, P = NS). All patients who died, and three of five survivors, had preoperative fever (greater than 99.0 F), leukocytosis (greater than 12,000/mm3), and persistent tachycardia despite adequate hydration and blood replacement. Perforation in bleeding peptic ulcers is not an uncommon finding, and was present in 9.9 per cent of patients. The presenting symptom of bleeding may obscure signs of perforation, delay surgery, and contribute to the higher mortality rate. The presence of fever, leukocytosis, and tachycardia despite adequate fluid and blood replacement warrants a suspicion of perforation in patients with bleeding peptic ulcer.