Gastroduodenal Perforation Research Articles

Long-term therapeutic results in patients with perforated gastroduodenal ulcer operated on by simple closure and pharmacal management

Objective To investigate the long-term follow up results of patients with gastroduodenal ulcer perforation managed by simple suture and pharmacal management.Methods 74 patients with perforated gastroduodenal ulcer operated with simple closure and pharmacal management in hospital from February 1990 to May 2005 were observed,after operation the patients underwent follow-up.According to follow-up data,the long-term therapeutic results of these patients were determined.Results The rate of symptomatic ulcer recurrence(Visick Ⅲ-Ⅳ)was14.9%(26.9% in patients with gastric ulcer and 8.3% in duodenal ulcer)in 74 patients with perforated gastroduo denal ulcer operated on with simple closure and pharmacal management after operation.Both of them showed significant difference(Fisher' s Exact Test:P = 0.043).The incidence of long-term complications was 10.8% and there was no statistical difference between the patients with gastric ulcer and those with duodenal ulcer(Fisher's Exact Test:P =0.440).56 patients were surveyed by endoscopy or upper gastrointestinal series within 6 months after operation.The rate of cure was 91.1% ,significant difference was not observed between the patients with gastric ulcer and those with duodenal ulcer(Fisher' s Exact Test:P = 0.336).But after a year ulcer recurrence rate of total 46 patients was 10.9% and the gastric ulcer recurrence rate significantly higher than that of duodenal ulcer(Fisher's Exact Test;P = 0.047).Conclusion Long-term effect of patients with perforated gastroduodenal ulcer operated by simple closure and pharmacal management was satisfactory.But the former was less effective than the latter. Key words: Peptic ulcer perforation; Antacids

What determines the periportal free air, and ligamentum teres and falciform ligament signs on CT: Can these specific air distributions be valuable predictors of gastroduodenal perforation?

Purpose The purpose of this retrospective study was to determine what gives rise to the periportal free air, and ligamentum teres and falciform ligament signs on CT in patients with gastrointestinal (GI) tract perforation, and whether these specific air distributions can play a clinically meaningful role in the diagnosis of gastroduodenal perforation. Material and methods Ninety-three patients who underwent a diagnostic CT scan before laparotomy for a GI tract perforation were included. The readers assessed the presence of specific air distributions on CT (periportal free air, and ligamentum teres and falciform ligament signs). The readers also assessed the presence of strong predictors of gastroduodenal perforation (focal defects in the stomach and duodenal bulb wall, concentrated extraluminal air bubbles in close proximity to the stomach and duodenal bulb, and wall thickening at the stomach and duodenal bulb). The specific air distributions were assessed according to perforation sites, and the elapsed time and amount of free air, and then compared with the strong predictors of gastroduodenal perforation by using statistical analysis. Results All specific air distributions were more frequently present in patients with gastroduodenal perforation than lower GI tract perforation, but only the falciform ligament sign was statistically significant ( p < 0.05). The presence of all three specific air distributions was demonstrated in only 13 (20.6%) of 63 patients with gastroduodenal perforation. Regardless of the perforation sites, the falciform ligament sign was present significantly more frequently with an increase in the amount of free air on multiple logistic regression analysis (adjusted odds ratio, 1.29; p < 0.001). The sensitivity, specificity, accuracy, and positive predictive and negative predictive values of each strong predictor for the diagnosis of gastroduodenal perforation were higher than those of specific air distributions. The focal wall thickening (accuracy, 95.7%) was the most useful parameter for the diagnosis of gastroduodenal perforation. Conclusion The prediction of the perforation site of the GI tract on CT should be based on the presence of strong predictors of the site of bowel perforation, and the specific free air distribution should be regarded as complementary predictors.

The Epidemiology of Intra-Abdominal Flora in Critically Ill Patients with Secondary and Tertiary Abdominal Sepsis

Background: Different micro-organisms can be cultured from abdominal fluid obtained from patients with intra-abdominal infection resulting from a perforated digestive tract. We evaluated a cohort of patients with abdominal sepsis admitted to the intensive care with the aim of obtaining more insight into the type of microorganisms involved and the efficacy of treatment. A 5-year prospective observational cohort study was performed in patients admitted to the intensive care unit with abdominal sepsis syndrome, defined as a perforation of the digestive tract and inflammatory response with organ failure. Abdominal fluid was obtained for microbial culture during the surgical procedures and from abdominal drains. The initial treatment protocol was cefotaxim, ciprofloxacin, metronidazole, and amphotericin B, tailored according to microbiological results. Selective decontamination of the digestive tract was administered to prevent secondary endogenous infections. Abdominal fluid was taken for microbial culture from 221 of the 239 patients admitted with abdominal sepsis. Aerobic Gram-negative bacteria (AGNB) were found in 52.9% of the cultures of abdominal fluid taken at the time of operation, of which 45% were Escherichia coli; in 36% of patients more than one AGNB was found. The incidence of AGNB was highest in colorectal perforations (68.6%) and perforated appendicitis (77.8%) and lowest in gastroduodenal perforations (20.5%). Gram-positive bacteria were found in 42.5% of the abdominal fluid cultures and most frequently in colorectal perforations (50.0%). Candida was found in 19.9% of patients, with 59.1% of these cultures being Candida albicans. The incidence of Candida was 41.0% in gastroduodenal perforations and 11.8% in colorectal perforation. Anaerobic bacteria were cultured in 77.8% of patients with perforated appendicitis. Over time, the prevalence of AGNB in abdominal fluid decreased from 117 patients (52.9%) in the first culture to one patient (6.7%) in week 4 (efficacy 87%). The prevalence of Gram-positive bacteria increased from 42.5% to 86.7% in a 4-week period. The composition of the intra-abdominal flora found in critically ill patients with abdominal sepsis varies depending on the location of the perforation. The efficacy of combined surgical and antibiotic treatment was 87% in 4 weeks for AGNB.

Perforación gástrica asociada a infección por Candida

Notable causes of gastroduodenal ulcer are Helicobacter pylori infection, intake of non-steroidal anti-inflammatory agents, neoplastic disease, acid hypersecretory states and secondary peptic ulcer disease. There are case reports of healthy patients or those with risk factors for fungal infection who develop gastroduodenal ulcer perforation associated with the presence of fungi in ascitic fluid or gastroduodenal ulcer tissue but without the above-mentioned etiological factors. Thus, other factors and pathogens may be involved in the pathogenesis of perforation. The use of antifungal agents in patients following surgery for a perforated gastroduodenal ulcer is controversial. We report two cases of healthy patients who underwent surgery for perforated gastroduodenal ulcer, in whom the most frequent causes of perforation were excluded. Only the presence of Candida in the ulcer was found.

Proton Pump Inhibitors for Gastroduodenal Damage Related to Nonsteroidal Anti-inflammatory Drugs or Aspirin: Twelve Important Questions for Clinical Practice

Nonsteroidal anti-inflammatory drugs (NSAIDs) and aspirin are among the most commonly used medications worldwide. Their use is associated with significant gastroduodenal adverse effects, including dyspepsia, bleeding, ulcer formation, and perforation. Given their long-term use by millions of patients, there is a substantial impact at the population level of these complications. In this evidence-based review, we have endeavored to answer 12 commonly encountered questions in clinical practice that deal with the following: extent of the problem of NSAID/aspirin-induced gastroduodenal damage and its impact on public health; role of proton pump inhibitors (PPIs) in the primary prevention, healing, and secondary prevention of NSAID/aspirin-induced gastroduodenal ulceration as assessed by using endoscopic end points; role of PPIs in the prevention of adverse clinical outcomes related to NSAID/aspirin use; whether PPIs are effective in NSAID-induced dyspepsia; comparison of PPI co-therapy with selective cyclooxygenase-2 inhibitors for risk reduction of adverse clinical outcomes; role of PPIs in preventing rebleeding from aspirin +/- clopidogrel therapy in high-risk patients; identifying high-risk patients who can benefit from PPI co-therapy; the role of other gastroprotective agents for prevention of NSAID/aspirin-induced gastroduodenal damage; and the cost-effectiveness of and limitations to the use of PPIs for prevention of gastroduodenal damage related to the use of NSAIDs or aspirin. We then summarized our recommendations on the use of PPIs for the clinical management of patients using NSAIDs or aspirin.

Successful treatment of gastric perforation with thyrotoxic crisis

Patients with thyrotoxic crisis presenting with another emergency are at a considerable risk. We report the successful treatment of a 55-year-old woman having gastric perforation with thyrotoxic crisis; the principle of treatment was delayed surgery after rapid preoperative restoration of thyroid function and cardiovascular status. The patient was admitted for severe abdominal pain and nausea with delirium, exophthalmos, diffuse goiter, tremulousness, diaphoresis, tabescence, pretibial edema, and atrial fibrillation. Computed tomography revealed free air over the liver surface. She had been diagnosed with uncontrolled hyperthyroidism 3 days before admission, with a free liothyronine (T 3) of 23.2 pg/mL, a free levothyroxine sodium (T 4) of greater than 7.78 ng/dL, and thyrotropin of less than 0.01 ng/mL. She was diagnosed with gastroduodenal perforation and thyrotoxic crisis, and we planned nonoperative management comprising nasogastric aspiration, cefmetazole sodium, omeprazole, thiamazole, and Lugol's solution. We also used landiolol, an ultrashort-acting β 1-adrenoceptor antagonist, and hydrocortisone. On the third day of admission, her thyroid function had improved with a free T 3 of 4.7 pg/mL and a free T 4 of 2.9 ng/dL; however, perforative peritonitis had worsened, and hence, omental patch repair was performed. She recovered uneventfully and was discharged after radioiodine administration. We discuss the management of a thyrotoxic patient with gastric perforation and focus on the importance of changing the management according to the patient's clinical course considering his thyroid function status and comparing the stress of surgery with that of perforative peritonitis in nonoperative management.

Treatment of Gastroduodenal Ulcer Perforation of 59 Cases with Acupuncture plus Sanbai Powder

Objective To investigate an effective method to treat gastric ulcer perforation with integrated traditional Chinese and western medicine. Methods 117 patients were randomly divided into a treatment group and a control group.The treatment group was treated with acupuncture plus Sanbal Powder, and the control group was treated with conventional western medicine exclusively. Results The two groups showed significant difference in the cure rate, the total efficiency, the average inpatient free, and the relapse rate in three years with P＜0.01. Conclusion The therapy of integrated traditional Chinese and western medicine will shorten inpatient time, alleviate pain and increase recovery rate when treating gastroduodenal ulcer perforation. Key words: Gastroduodenal ulcer perforation: Sanbai Powder: Acupuncture

Open versus Laparoscopic Management of Gastroduodenal Ulcer Perforation: A Single-Institution Comparative Experience

Background: Laparoscopic repair of perforated ulcers has been recently proposed as an alternative to the conventional (open) technique. However, the advantages of the laparoscopic method are less apparent in most published series. This study compared the outcomes of laparoscopic and open approaches for the repair of gastroduodenal perforations, and assessed the feasibility and efficiency of the laparoscopic approach. Patients and Methods: From July 2002 to July 2006, 176 patients with a preoperative diagnosis of perforated peptic ulcer were identified. The following parameters have been retrospectively analyzed to measure and compare the outcomes: operative time, length of hospital stay, blood loss, and postoperative complications. All patients were analyzed on an intention-to-treat basis. Results: Two cases with gastric cancer were excluded form this study. Of the remaining 174 patients, 90 underwent open repair of a perforated ulcer, and 84 were commenced laparoscopically including 6 conversions to open procedure. The 2 groups were matched for age, gender, and other patient characteristics. The laparoscopic group had less blood loss, earlier bowel function, lower dosage of analgesic drugs, shorter hospitalization time, and lower total morbidity, but there was no significant difference in the mean operating time between 2 groups. Conclusions: Laparoscopic repair of perforated ulcers is technically feasible. It is a minimally invasive technique with the benefits of less blood loss, shorter hospitalization, quicker return of bowel function, and a lower dosage of analgesic drugs.

Outcomes of Cocaine-Induced Gastric Perforations Repaired With an Omental Patch

Crack cocaine has been associated with acute gastric perforation. The appropriate surgical treatment and long-term outcomes remain unclear. A retrospective chart review of all gastroduodenal perforations associated with crack cocaine use was performed. Data abstracted included details of short- and long-term outcomes. Kaplan–Meier methods were used to evaluate surgical outcomes. Over the 14-year period ending December 2005, 16 cases of crack-induced gastric perforations were identified. Most (75%) were treated with an omental patch. The other patients underwent a formal antiulcer operation, including one vagotomy and pyloroplasty (V&P), one vagotomy and antrectomy, one subtotal gastrectomy, and one ulcer excision and V&P. All patients after antiulcer procedures were followed for a median of 63 months (range 27–120) with no recurrences. Follow-up data were available in 75% of the omental patch patients. Recurrence of disease was observed in 56% of these omental patch patients at a median of 20 months (range 11–39). Those without recurrence were followed for a median of 67 months (range 12–96). The recurrence rate was borderline lower in the antiulcer group (P = 0.072). Omental patch closure results in a recurrence rate over 50% compared with no recurrence for formal antiulcer procedures.

PERFORATED PEPTIC ULCERS: TO RAISE THE RPOBLEM

In order to identify the possibility of time regularity in the appearance of such ulcer complication as perforation, a study of 2200 cases of perforating ulcer incidence within the period of 1986-2005 among Gomel population has been performed. The study results have not confirmed the widespread theory of prevailing frequency of gastroduodenal ulcer perforations in spring and autumn. Dominant friqenst of perforated peptic ulcers (PPU) can be marked in any season of the year. The stated decrease in incidens of PPU - is taking place in winter season.

High-Dose Oral Erythromycin Decreased the Incidence of Parenteral Nutrition-Associated Cholestasis in Preterm Infants

Background & Aims: Feeding intolerance because of functional gastrointestinal dysmotility and parenteral nutrition-associated cholestasis (PNAC) are common problems in preterm, very-low-birth-weight (VLBW) infants. This double-blind, randomized, placebo-controlled study aimed to assess the effectiveness of “high-dose” oral erythromycin as a prokinetic agent in decreasing the incidence of PNAC. Two secondary end points, including the time to achieve full enteral feeding and the duration of parenteral nutrition, were also evaluated. Methods: Infants consecutively admitted to the neonatal unit were randomized to receive erythromycin (12.5 mg/kg/dose every 6 hours for 14 days) or an equivalent volume of normal saline (placebo) if they attained less than half the total daily fluid intake (<75 mL/kg/day) as milk feeds on day 14 of life. Results: Of 182 VLBW infants enrolled, 91 received erythromycin. The incidence of PNAC was significantly lower in erythromycin-treated infants (18/91) compared with placebo infants (37/91; P = .003). Treated infants achieved full enteral nutrition significantly earlier (mean, 10.1; SE, 1.7 days; P < .001), and the duration of parenteral nutrition was also significantly decreased by 10 days (P < .001). Importantly, fewer infants receiving erythromycin had 2 or more episodes of septicemia (n = 4) compared with placebo patients (n = 13, P = .03). No serious adverse effect was associated with erythromycin treatment. Conclusions: High-dose oral erythromycin can be considered as a rescue measure for VLBW infants who fail to establish adequate enteral nutrition and in whom anatomically obstructive pathologies of the gastrointestinal tract have been excluded.

Value of Computed Tomography in the Diagnosis of the Cause of Nontraumatic Gastrointestinal Tract Perforation

To identify computed tomographic features with a high predictive value to differentiate gastroduodenal ulcer perforations from other causes of perforations in patients with a non-traumatic-free pneumoperitoneum. Computed tomographic scans of 81 patients with a non-traumatic-free pneumoperitoneum were reviewed for direct visualization of the perforation site and indirect findings of the perforation, including the presence, amount, and localization of air and ascites in the peritoneal cavity, mural thickness of the gastrointestinal tract, perigastrointestinal fat stranding, intestinal ischemia, fecal peritonitis, abscess, and portomesenteric venous gas. The perforation site was directly visualized in 16 (41%) of 39 patients with gastroduodenal ulcer perforation and in 5 (12%) of 42 patients with other causes of perforation. The findings with a positive predictive value of more than 90% for gastroduodenal ulcer perforation were the presence of local fluid between the duodenum and the pancreatic head and the combination of local gastroduodenal wall thickening and fat stranding. The presence of abscess in the peritoneal cavity or fecal peritonitis, portomesenteric gas, or bowel ischemia findings had a positive predictive value of 100% for the diagnosis of other perforations. Indirect computed tomographic findings are helpful for differentiating gastroduodenal ulcer perforation from other causes of perforations.

Le scanner multi détecteurs améliore la détection des perforations d’ulcères gastro duodénaux

Objective To determine whether multidetector computed tomography (MDCT) is helpful for early detection of gastroduodenal perforation. Material and methods Fifteen consecutive gastroduodenal perforations for ulcer were recorded in the HIS of a single institution. Reports were analyzed and classified according to the following signs: Was a pneumoperitoneum detected? Was there mention of a perforation site, and how was it depicted (axial or reformatted slices, thin or thick slices)? What were the other described features, including peritoneal fluid, abdominal fat blurring, and bowel wall thickening? Results All patients had a gastroduodenal perforation. MDCT identified pneumoperitoneum in 15 of 15 cases as compared with three of nine cases for plain films. The perforation site was seen in eight of 15: it was identified as a defect in the parietal wall (gastroduodenal). Six of eight cases were depicted in axial view. Two of them were only seen on MPR, coronal or sagittal view. Conclusion MDCT improves the detection rate of pneumoperitoneum and provides critical data for locating the perforation using direct and indirect signs. Multiplanar images seem to improve radiologists’ confidence.

Twelve years’ progress in surgery for perforated gastric and duodenal ulcers: a retrospective study of indications for laparoscopic surgery, post‐operative course and the influence of Candida infection

SummaryBackgroundTwelve years has passed since we introduced laparoscopic surgery for gastroduodenal perforation.AimTo list problems and to investigate the feasibility of our clinical protocol for treatment of gastroduodenal ulcer perforation.MethodsCase records of 62 patients and histology samples of 9 patients undergoing surgery for gastroduodenal perforation were retrospectively reviewed.ResultsLaparoscopic omental implantation is feasible for some cases of perforated peptic ulcer in patients who have either stenosis or massive perforations. In patients undergoing laparoscopic omental implantation, oral ingestion of water was started at 3.3 ± 0.5 post‐operative days. Helicobacter pylori was positive in 27 of 35 patients (77%). Of 22 cases in whom intraoperative ascitic culture was taken, Candida was positive in nine (41%), and in six of eight cases involving wound infection or intraperitoneal abscess. Histological examination of resected stomach revealed the fungi with hypha formation at the base of the ulcer in 44% of patients.ConclusionsLaparoscopic omental implantation was more feasible than in the past. The possibility of Candida infection and subsequent abscess formation must be considered in patients with gastroduodenal ulcer perforation.

ACUTE SURGICAL ADMISSIONS FOR ABDOMINAL PAIN IN ADULTS IN KUMASI, GHANA

Abdominal pain of less than a weeks' duration is the presenting complaint in one of every five patients admitted to the surgical Accidents and Emergency Ward of the Komfo Anokye Teaching Hospital in Kumasi. This study is a prospective one, to determine the cause of abdominal pain in a large number of patients. A monthly audit of discharge summaries for all patients admitted with acute abdominal pain was prepared and transferred to a special study pro forma to provide data over the 84-month period from January 1998 to December 2004. There were 3114 patients, 2070 men and 1044 women. The ages ranged from 15 to 95 years. The seven most common causes of the admissions were acute appendicitis 698 (22.4%), typhoid ileal perforation (506) 16.2%, acute intestinal obstruction 391 (12.6%), gastroduodenal perforations 342 (11.0%), non-specific abdominal pain 306 (9.8%), abdominal injures 260 (8.3%) and acute cholecystitis 102 (3.2%). There were 1976 (63.4%) emergency operations. Appendicectomy was a common operation that was carried out (638 cases or 32.3%). Two hundred and thirty patients (7.4%) died. Thirty-five patients died before and 195 after operation. Of these 230 deaths, 110 (47.8%) reported to the hospital after three or more days of illness. Twenty-six per cent and 23.7% of postoperative deaths occurred after emergency colonic resections and closure of gastroduodenal perforations, respectively. Acute appendicitis, typhoid ileal perforation, acute intestinal obstruction and gastroduodenal perforations were the leading causes of acute admissions for abdominal pain to our hospital. Late presentation was associated with increased mortality.

Twelve years’ progress in surgery for perforated gastric and duodenal ulcers: a retrospective study of indications for laparoscopic surgery, post‐operative course and the influence of Candida infection

SummaryBackgroundTwelve years has passed since we introduced laparoscopic surgery for gastroduodenal perforation.AimTo list problems and to investigate the feasibility of our clinical protocol for treatment of gastroduodenal ulcer perforation.MethodsCase records of 62 patients and histology samples of 9 patients undergoing surgery for gastroduodenal perforation were retrospectively reviewed.ResultsLaparoscopic omental implantation is feasible for some cases of perforated peptic ulcer in patients who have either stenosis or massive perforations. In patients undergoing laparoscopic omental implantation, oral ingestion of water was started at 3.3 ± 0.5 post‐operative days. Helicobacter pylori was positive in 27 of 35 patients (77%). Of 22 cases in whom intraoperative ascitic culture was taken, Candida was positive in nine (41%), and in six of eight cases involving wound infection or intraperitoneal abscess. Histological examination of resected stomach revealed the fungi with hypha formation at the base of the ulcer in 44% of patients.ConclusionsLaparoscopic omental implantation was more feasible than in the past. The possibility of Candida infection and subsequent abscess formation must be considered in patients with gastroduodenal ulcer perforation.

Diagnosis and treatment experiences of 198 cases of acute gastroduodenal perforation

目的 探讨胃十二指肠穿孔的病因、诊断及治疗方法.方法对本院198例急性胃十二指肠穿孔患者的f临床资料进行回顾性分析.结果胃溃疡穿孔44例,十二指肠溃疡穿孔146例,胃癌穿孔8例;治愈192例,死亡6例.手术治疗196例,其中行胃十二指肠穿孔修补术188例,胃大部切除术8例,非手术治疗2例.结论消化性溃疡是胃十二指肠穿孔的主要病因,胃管内注人空气可提高胃十二指肠穿孔的诊断率.穿孔修补术仍是治疗胃十二指肠穿孔的有效方法。

Life threatening abdominal complications following cocaine abuse

Life threatening abdominal complications following cocaine abuse

Laparoscopic treatment of gastroduodenal perforations: comparison with conventional surgery

Laparoscopic techniques have been proposed as an alternative to open surgery for the treatment of peptic ulcer perforation. This study compared the outcome of laparoscopic and open approaches for the repair of gastroduodenal perforations. A retrospective review was conducted with 134 consecutive patients treated for gastroduodenal perforations. These patients included 122 with perforated duodenal ulcers, 10 with perforated gastric ulcers, and 2 with iatrogenic duodenal perforations. Whereas 68 patients were treated laparoscopically, 66 patients underwent conventional (open) surgery. Laparoscopic repair was successful in 65 cases (96 %). The mean operating time was shorter with the laparoscopic technique (68 vs 59 min), but the difference was not significant. The duration of postoperative nasogastric aspiration and time to resumed oral intake were shorter in the laparoscopic group (2.6 vs 4.1 days and 4.4 vs. 5.2 days, respectively; p = 0.043). The postoperative analgetic requirements, and overall complications rate were significantly lower after laparoscopic surgery (p = 0.03 and p = 0.004, respectively). There was no statistically significant difference in hospital stay (5.1 vs 6.1 days) or mortality rate between the two procedures. Laparoscopic repair of gastroduodenal perforations is a safe alternative treatment offering certain significant short-term advantages.

Causes of acute peritonitis in 1188 consecutive adult patients in Ghana

In a five-year prospective study, 1188 consecutive adult patients were admitted and treated for acute generalized peritonitis at the Surgical Emergency Unit of the Komfo Anokye Teaching Hospital, Kumasi, Ghana. Appendicitis and typhoid ileal perforation were the commonest causes, occurring in 43.1% and 35.1% of patients, respectively. Other conditions (gastroduodenal perforations, ruptured abscesses, traumatic bowel perforations and amoebic colonic perforations) accounted for fewer than 25% of cases.