Clinical patterns of presentation and attenuated inflammatory response in octo- and nonagenarians with perforated gastroduodenal ulcers

Abstract

Perforated gastrodudenal ulcer (PGDU) is an operative emergency with high mortality rates. The growing elderly population increasingly presents with need for geriatric acute operative care. Current knowledge of age-specific characteristics in presentation, diagnosis, and outcome for PGDU in the elderly is scarce. We reviewed a consecutive, population-based cohort of patients with PGDU, octa- and nonagenarians were compared with younger patients for variation in patterns of presentation and outcomes. Patterns and outcomes observed included 30-day mortality, serious complications (Clavien-Dindo 3 and 4), and duration of stay. Of the 244 patients, 127 were women (52%); median age was 68years; and 59 patients (24.2%) were ≥80years. Two thirds had gastric ulcers (n=168; 67.2%). On admission, hemoglobin levels, white blood cell count, and serum levels of C-reactive protein, bilirubin, and albumin differed significantly between the age groups. Diagnosis, treatment, and the occurrence of severe complications did not differ with age. The median hours of delay to definitive treatment did not differ significantly for all ages, but patients ≥80years had a greater proportion (44.1% compared with 25.8%) of delay >12hours (odds ratio 2.26, 95% confidence interval 1.22-4.17; P=.008). Overall mortality was 38 (15.6%); no deaths occurred in patients <55years. Over one half of deaths occurred in those ≥80years (odds ratio 4.76, 2.30-9.83; P<.001). Duration of hospital stay was significantly greater in elderly survivors, and fewer were discharged within a week. Octa- and nonagenarians with PGDU present with fewer signs of peritonitis and have an attenuated inflammatory response. The very elderly have twice the risk of long delays to definitive treatment and almost 5 times increased risk of mortality.