Perforated Gastric Ulcer Research Articles

Perforated peptic ulcer in Hong Kong and New South Wales.

Direct comparisons of ulcer perforation rates and trends between countries have not been made in the past. Data on hospital admissions for perforated peptic ulcer during 1 January 1979 to 31 December 1985 were collected in Hong Kong (5868 perforations) and New South Wales, Australia (1669 perforations). Age and sex specific rates per 100,000 population were calculated. In Hong Kong, annual duodenal ulcer and gastric ulcer perforation rates were 13-16 and under two per 100,000 population respectively. In New South Wales, the corresponding rates were between three and four and under two per 100,000 population, respectively. The male:female ratios for duodenal ulcer perforation were consistently about 5:1 in Hong Kong and 2:1 in New South Wales, and for gastric ulcer perforation about 2:1 and 1:1, respectively. The incidence of perforation increased with age, and there was a statistically significant rise, over time, in duodenal but not gastric ulcer perforation rates in persons aged over 60 years in New South Wales; similar trends were seen in Hong Kong. Thus duodenal ulcer perforation occurs five times more commonly in Hong Kong than in New South Wales and this is largely accountable for by the higher rates of duodenal ulcer perforation in Chinese than in Australian males. Such geographical differences can best be explained by the occurrence of multiple aetiological mechanisms in ulcer perforation. Furthermore, there appears to be an increased susceptibility and an appreciable rising trend for duodenal ulcer perforation to occur in the elderly.

Peritonitis causing acute limb ischaemia

A patient presented with an acutely ischaemic leg and mild abdominal pain. Arteriography showed an iliac occlusion and some distal occlusive disease. At laparotomy a perforated gastric ulcer was found, and by the end of this operation the foot was well perfused. This case exemplifies the serious reduction in limb blood supply which can be caused by an acute illness, without thrombosis of vessels. It emphasises the importance of general assessment and treatment of any associated acute condition, in cases of acute limb ischaemia.

Perforated peptic ulcer in the Hunter region: a review of 174 cases.

A review of 174 consecutive patients admitted with a diagnosis of perforated peptic ulcer to eight Hunter Region hospitals during 1979-86 is presented. Among the female admissions, the proportion of patients greater than 70 years of age was twice that in males. One-third of all perforations were in females who accounted for two-thirds of all perforated gastric ulcers. Multivariate analysis revealed that perforations located in the stomach and older age were both significant independent variables adversely affecting outcome following surgery. In contrast, shock at presentation and delay in operating were not statistically significant independent risk factors.

Alfred Parsons on suspected perforated gastric ulcer. 1892.

Alfred Parsons (1864-1952) was noted for his vigour of mind and body and Spartan habits and his dramatic teaching. In 1891 while a junior doctor he cared for three fatal cases of acute perforation of a chronic ulcer of the stomach. In May 1892 he made a passionate plea for early diagnosis and surgery in this condition. The first successful operation was performed in the same month by Ludwig Heusner in Germany.

A CASE OF PERFORATED EARLY GASTRIC CANCER AND A REVIEW OF 45 CASES COLLECTED FROM THE JAPANESE LITERATURE

An 80-year-old man was seen at the hospital because of abrupt abdominal pain. The abdomen was board-like, and a simple X-ray film revealed free air. The patient was diagnosed as panperitonitis due to a perforated gastric ulcer. Emergency operation was carried out. During operation, a hard induration of 6 cm in diameter with an 8 mm perforation in its center was confirmed in the anterior wall of upper body of the stomach. Intraoperative fiberscope revealed a perforated advanced gastric cancer (P0H0N2S2) and gastrectomy with lymph node dissection was performed. Surgical specimen revealed that the moderately differentiated tubular adenocarcinoma invading the submucosal layer around the ulcer in the gastric wall. It was diagnosed as perforated early gastric cancer of type III+IIc histopathologically. In the diagnosis of gastric perforation, we should emphasize the importance to perform intraoperative frozen section diagnosis whenever possible and to follow post operative patients undergone simple suture by using gastric fiberscope. Forty-five cases of perforated early gastric cancer collected from the Japanese literature were also discussed.

A CLINICAL STUDY OF PERFORATION OF GASTRODUODENAL ULCER

During the period from August 1974 to December 1990, 115 cases of gastric, 97 of duodenal and 23 of combined gastroduodenal ulcer were operated on for gastroduodenal ulcer at the department. Among these cases, operation for perforation was carried out in 8 of gastric, 37 of duodenal and 3 of combined gastroduodenal ulcer. The incidences of perforation were 7.0%, 38.1% and 13.0%, respectively. Since all 3 cases of combined gastroduodenal ulcer developed perforation in the duodenal ulcer, these cases were included in the duodenal perforation group. The ratio of perforation in gastric to duodenal ulcer was 1:5, indicating that the majority of perforation occurred in the duodenal ulcer. The male to female ratio was 6:1, showing a high prevalence of males. Young men were more likely to have duodenal perforation than gastric perforation. The incidence of free air on the plain X-ray film was 75.0% in gastric perforation and 97.5% in duodenal ones. Epigastric sudden pain occurred in 50.5% of gastric and 87.5% of duodenal perforation cases, respectively. Anamnesis of ulcer disease was recognized in 62.5% of perforated gastric ulcer and 47.5% in perforated duodenal ulcer cases. The overall mortality rate was 8.3% (4 cases).

Perforated gastric ulcer v associated with pyloroplasty for chronic hypertrophic pyloric gastropathy in a dog

ABSTRACTA six‐year‐old male silkie terrier presented with a history of chronic vomiting. A diagnosis of gastric outflow obstruction was made using contrast radiography of the upper gastrointestinal tract. Surgical examination of the stomach revealed thickened pyloric antral mucosa. A Heineke‐Mikulicz pyloroplasty combined with resection of the hypertrophic pyloric mucosa were performed to increase the patency of the pyloric lumen. The dog recovered well from surgery and his condition remained stable until the sixth day postoperatively when his condition deteriorated rapidly resulting in his death that night. At autopsy a perforated gastric ulcer was found in the cardiac region of the pylorus with evidence for a generalised peritonitis. An association between gastric outflow obstruction and gastric ulceration has been reported in human clinical literature and in canine experimental models. No such association has been previously documented in the veterinary clinical literature.

Épidémiologie et traitement des lésions gastroduodénales provoquées par les médicaments anti-inflammatoires non stéroïdiens

The most common serious adverse reactions to nonsteroidal anti-inflammatory drugs (NSAIDs) are those affecting the gastro-intestinal tract. There is epidemiologic evidence that NSAIDs use is associated with the development of gastric ulcer and with upper gastrointestinal bleeding and perforation of both duodenal and gastric ulcers. The individual risk is low but given the widespread use of NSAIDs, the number of cases is large with appreciable morbidity and mortality. The main risk factors are age above 65, previous ulcer history and treatment with several NSAIDs. Prophylactic therapy is justified in high risk patients. Synthetic prostaglandin misoprostol has been shown to reduce significantly the frequency of gastric ulcer in patients on NSAIDs. By contrast, H2 receptor blockade with ranitidine has been demonstrated to prevent duodenal but not gastric ulcers. Gastric and duodenal ulcers associated with NSAIDs appear to heal on H2 receptors antagonists and prostaglandins even if NSAIDs are continued. However, large gastric ulcer may heal slowly over 8 to 12 weeks. The place of omeprazole remains to be determined.

COMPLICATED PEPTIC ULCER DISEASE IN CHILDHOOD: AN OVERLOOKED DIAGNOSIS

SUMMARY Primary peptic ulceration is no longer regarded as a rare disease of childhood, but its exact incidence and pathogenesis remain debatable. We report the case of an 11 ‐year‐old boy, who presented with a perforated primary gastric ulcer, a rare complication in this age group.

Crack-Related Perforated Gastropyloric Ulcer

Cocaine is a potent topical vasoconstrictor that causes nasal mucosal and dermal ulceration. Use of the purified cocaine derivative "crack" has reached epidemic proportions in large cities. In 18 months we operated on 24 patients with perforated peptic ulcers. Five of the patients were young (27-38 years) male crack users without prior history of gastric symptoms who presented with a perforated gastric ulcer related to smoking crack. Three had had symptoms for only 1-5 days before admission. All five were afebrile, had a rigid abdomen, normal leukocyte count, and free intraabdominal air upon radiography. Five other age-matched, non-crack-using patients served as case controls. Their duration of symptoms was 1-24 months, they had elevated leukocyte counts on admission, and, in contrast to the crack users, four of these patients had duodenal perforations. The clinical presentation of the crack smokers and the unusual localization of the perforations imply different pathogenetic mechanisms than are commonly seen in perforated ulcer disease. With increasing abuse of crack, greater numbers of patients with this new complication may be expected to present to emergency services in urban areas.

Lndium-111 White Blood Cell Imaging in Suppurative Peritonitis

An 85-year-old man underwent en bloc resection of the distal two-thirds of his stomach and pancreas, splenectomy, left hemicolectomy, and left kidney resection for malignant lymphoma. A large perforated gastric ulcer and massive lymphadenopathy were seen at the time of surgery. Postoperatively, his temperature peaked and an ln-111 WBC study and repeat CT imaging of the abdomen were performed. On repeat laparotomy, about 3 L of purulent material were drained from the peritoneal cavity.

Haemophilus Isolated from Unusual Anatomical Sites

During a 15-year period Haemophilus species were isolated from unusual anatomical sites in 80 patients, mostly adults. The origin of specimens was pus and swabs from suppurative lesions, fluids from serosal cavities and gall bladder, gut content, and blood in cases with a supposed tissue focus. In 17 patients Haemophilus species were isolated in pure culture, in 63 patients in conjunction with other bacteria. 17 patients had gynaecological complaints: bartholinitis, salpingitis, and vaginal discharge. 22 patients had gastrointestinal complaints, comprising 17 with appendicitis, peritonitis following perforation of gastric ulcer, gall-duct infections, and an abscess in the stomach wall, and 5 patients with colonization of the gut. 41 patients had soft tissue and bone infections.

アジソン病様症状で発症した副腎非ホジキンリンパ腫

A 65-year-old man who presented with adrenal insufficiency was admitted on Feburuary 9, 1988. CT scan showed bilateral swelling of adrenals; open biopsy of the tumor revealed non-Hodgkin's lymphoma. The serum level of catecholamines and calcitonin was elevated. A combination chemotherapy was started. After 3 courses of the treatment remission was achieved, following recovery from adrenal insufficiency. In November, 1988, he had pulmonary infiltration and high fever, resolved by the administration of antibiotics and antifungal drugs. On January 27, 1989, he underwent emergency operation because of perforation of gastric ulcer. In Feburuary, tumor increased in size, and the disease became progressive. On April 2, 1989, he died of respiratory failure. Autopsy revealed a definite diagnosis of malignant lymphoma, diffuse large cell type. Immunohistological studies revealed B cell origin of the cells based on positive LCA and pan B markers.

Non-steroidal anti-inflammatory drug ingestion: retrospective study of 272 bleeding or perforated peptic ulcers.

The ingestion of non-steroidal anti-inflammatory drugs (NSAID) in 272 patients with bleeding or perforated peptic ulcer was compared with 272 age/sex matched controls. A significantly higher proportion of patients with gastric ulcers had received NSAID than those with duodenal ulcers. Twelve of 90 (13%) patients admitted with bleeding duodenal ulcers had received NSAID compared with 11 of 26 (42%) patients with bleeding gastric ulcers (P = 0.003). Sixteen of 132 (12%) patients with perforated duodenal ulcer were taking NSAID compared with 8 of 24 (33%) patients with perforated gastric ulcer. Thirty eight percent of patients with both bleeding and perforated gastric ulcers had received NSAID compared with 13% bleeding and perforated duodenal ulcers (P less than 0.002). This study confirms the association of NSAID and complicated peptic ulcer in patients of over 65 years and highlights the particular susceptibility of the gastric mucosa to their injurious effect.

Gastropyloric Ulcers Related to 'Crack'

To the Editor.— Numerous cocaine complications have been described since appeared on the streets of our largest cities. 1 Over the last 18 months we have operated on several young men with perforated gastric ulcers in our large municipal hospital that serves a poor black population. Among a total of 23 patients with perforated ulcers, 5 were young male crack users (ages, 27 to 38 years) without a history of gastric symptoms who had perforated gastric ulcers (two of which were pyloric) related to smoking crack. Compared with age-matched, non—crack-using control patients operated on during the same period, the crack users had a shorter duration of symptoms (1 to 5 days vs >30 days), lower leukocyte counts (3.4×10 9 /L to 9.7×10 9 /L vs 12.2×10 9 /L to 14.0×10 9 /L), and a shorter length of stay (7.6 vs 9.5 days). The location of the perforation (gastric rather

All perforated ulcers are not alike.

To determine if ulcer location and other clinical factors affect the hospital course and early outcome of patients with perforated peptic ulcers in the decade since the introduction of H2 receptor antagonists, the records of 80 patients with perforated peptic ulcers were analyzed. Demographic factors, clinical features, and the outcome of patients with duodenal ulcer perforation were similar to patients with prepyloric ulcer perforation. In contrast, patients with gastric ulcer perforation had differing characteristics from the group with perforated pyloroduodenal ulcers. Overall, NSAID use preceded perforation in one half of the patients; severe coexisting medical illness and a short interval of symptoms before perforation were seen in more than one half of patients. Gastric ulcer location, hemodynamic instability, greater degree of peritoneal contamination, and larger ulcer size were factors associated with increased rates of mortality. Overall mortality rate was 12.5% and rate of morbidity was 33%. Oversewing with or without omental patch was the operation most commonly employed by a diverse group of surgeons.

Prevention of Gastroduodenal Injury Induced by Chromic Nonsteroidal Antiinflammatory Drug Therapy

The fact that nonsteroidal antiinflammatory drugs (NSAIDs) damage the gastroduodenal mucosa is now accepted as NSAID use has been associated with a disproportionately high frequency of upper gastrointestinal bleeding and perforation of gastric and duodenal ulcers. More than 10% of patients receiving NSAIDs chronically will have a gastric ulcer on any given day, a point prevalence of ulcer disease 5-10 times higher than in patients who are not taking NSAIDs. Endoscopic studies comparing the effect of acute administration of NSAIDs on the gastroduodenal mucosa in normal volunteers have failed to predict which NSAIDs would be safest when administered chronically. All of the newer NSAIDs appear to be similar in their propensity to cause chronic mucosal damage, including peptic ulceration. Recent studies have suggested that in those starting NSAID therapy, prophylactic cotreatment with H2-receptor antagonists or sucralfate has minimal or no effect on preventing the development of NSAID-induced gastric ulcers, although duodenal ulcers may be reduced. Nonsteroidal antiinflammatory drug-induced gastric ulcers are also not prevented by drug formulations that prevent or markedly reduce the amount of active NSAID in the stomach. Cotreatment with the synthetic prostaglandin misoprostol was associated with a marked reduction in gastric ulcer development in patients with osteoarthritis receiving NSAIDs chronically, suggesting that prevention of prostaglandin generation in the gastric mucosa may play a pivotal role in NSAID-induced gastric ulcers.

The Need for Definitive Therapy in the Management of Perforated Gastric Ulcers. Review of 202 cases

A retrospective study of 202 patients who presented to three Louisiana hospitals with perforated gastric ulcers was performed. Patients were treated surgically, medically, or were not treated. Only those patients with gastric ulcers were included in the study, not those with "channel ulcers" or peptic ulcers. The mortality rate of the 185 patients who were treated with operation was 18%. Of those patients treated nonoperatively, the mortality was 95% (one survivor). There was a definite difference in mortality among those patients treated with definitive operative procedures (11.3%) versus those patients treated with nondefinitive surgery (22.9%). This difference was consistent even in the presence of purulent exudate in the abdominal cavity and among those patients presenting in shock. The mortality among those patients who presented with a initial blood pressure of 90 mmHg or less were defined as being in shock, and the mortality in this subgroup was 52.8%. The mortality among those patients who had purulent fluid within the abdominal cavity was about the same, regardless of type of surgical procedure. The patients who underwent nondefinitive procedures required subsequent operative treatment in 25.7% of cases. Also noted was the lack of correlation between symptoms of ulcer disease and perforation. Those patients treated with definitive surgery (57%) and those treated with nondefinitive surgery (41%) reported no symptoms consistent with ulcer disease before operation.

Intrathoracic Perforation of Gastric Ulcer in the Hiatus Hernia of a Cirrhotic Patient

Intrathoracic Perforation of Gastric Ulcer in the Hiatus Hernia of a Cirrhotic Patient

THE DIAGNOSIS AND TREATMENT OF GASTRODUODENAL PERFORATION IN PATIENTS AGED 80 YEARS ON OVER

This paper reports possible problems such as delayed diagnosis, and frequently occurred pre-and postsurgical complications in aged patients with gastro-duodenal perforation. A total of 83 cases of gastro-duodenal perforation was operated in our department of Miyazaki Shigun-Ishikai Hospital since its opening, and 7 of which were of advanced ages of 80 years or over and subjected to the study. The male-to-female ratio was 1/6. The 7 cases included 2 of perforated gastric ulcer 4 of perforated duodenal ulcer and one of perforated gastric cancer. In patients of extremely advanced ages, it was difficult to reach a correct diagnosis, and the mean interval between the onset of perforation and the operation was 40 hours, resulting in various complications such as dehydration and shock leading to renal failure. Postsurgical complications also occurred frequently, delaying postsurgical remisson. The most problematic was renal failure; one case died of this. Important factors for the improvement of treatment included early diagnosis and prevention and treatment of postsurgical respiratory and circulatory complications.