Perforated Gastric Ulcer Research Articles

A Perforated Peptic Ulcer Contained by the Liver

Perforated peptic ulcers (PPU) are an uncommon, life-threatening disease with a mortality as high as 40%. Patients typically present acutely with chest pain, abdominal pain, and/or peritonitis, however they can also present with complications such as fistulas, abscess formation, or sepsis. We present a case of an elderly woman with an atypical presentation of a perforated gastric ulcer. An 88 year old woman was admitted with increasing fatigue, non-bloody emesis, and melena for 3 days. She denied abdominal pain, weight loss, dysphagia, odynophagia, NSAID or alcohol use. Her medical history was significant for well-controlled hyperparathyroidism and osteoporosis; her only medications included alendronate and cinacalcet. On initial evaluation, her blood pressure was 110/70 mmHg and her heart rate was 75 bpm. Physical examination revealed tarry black stool on rectal exam and a non-tender epigastrium. Basic laboratory studies exposed a Hgb of 6.4g/dl from her baseline of 10 g/dl. Blood chemistries, liver function tests, and coagulation studies were unremarkable. A chest X-ray revealed no free air under the diaphragm. Given for concern of blood loss from a GI source, an upper esophagogastroduodenoscopy (EGD) was performed, which showed one giant non-bleeding 6cm x 5cm, cratered, gastric ulcer with view of the liver through a 1 cm perforation (Image 1 & 2). Biopsies were negative for H. pylori and malignancy. She urgently underwent an emergent laparoscopic partial gastrectomy with gastrojejunostomy without complications. Post-operatively, she was successfully managed with antibiotics and pantoprazole with noted improvement on follow up 2 weeks later. Peptic ulcer disease (PUD) usually presents with iron-deficiency anemia and/or with upper gastrointestinal symptoms. This patient's presentation was most likely consistent with a slow upper gastrointestinal bleed; the absence of peritoneal signs and abdominal free-air made a perforated viscus less likely. However, the area of perforation in the gastric antrum was contained by a dynamic ascending and prolapsing liver, leading to this patient's delayed and atypical presentation. Modern PUD therapy via EGD and medications has rendered PPU an uncommon clinical scenario; PPU was once a more common surgical emergency. This case illustrates the variability in presentation of the already rare entity of PPU.Figure: Endoscopic image of a 5cm x 6cm non-bleeding, cratered ulcer with 1 cm perforation and view of extraluminal organ thought to be liver (marked by the yellow arrow) seen prolapsing in and out of the perforation.Figure: Wider view of large cratered ulcer on upper endoscopy. Base of the intact ulcer had adherent clots and adherent material without active bleeding.

Prevalence of Helicobacter pylori in peptic ulcer perforation

Background: Helicobacter pylori have an important role in the pathogenesis of peptic ulcer disease. The aim of the present study was to observe the prevalence of H. pylori in peptic ulcer perforation cases and the rationale of H. pylori eradication therapy post operatively and to investigate factors associated with peptic ulcer.Methods: This cross-sectional study was conducted at the Department of general surgery, Government Medical College, Kottayam for a period 20 months from March 2012 to October 2013 after getting approval from institutional ethics committee. A total of 113 patients were participated in the study after meeting inclusion criteria. After getting written consent from the patients with perforated peptic ulcer, resuscitation and laparotomy was performed in the emergency department. H. pyloriinfection was confirmed by histopathological examination by Giemsa staining. Based on the histopathological report, the prevalence of H. pylori infection in the patients was assessed and was given appropriate H. pylori eradication regimen.Results: The mean age of presentation of the patients was 52.81±14.5 years. Male to female ratio was 4.14:1. Out of 113 cases, 67 cases (59.3%) had duodenal ulcer perforation while 46 cases (40.7%) had gastric ulcer perforation. Of them 53(46.9%) cases were positive H. pylori positive. No significant association was found between the incidence of H. pylori infection in peptic ulcers with smoking, hypertension, diet intake, NSAIDS intake. In our study association between H. pylori and diabetes mellitus (p=0.02) found to be significant which can be further investigated.Conclusion: According to our study the prevalence of H. pylori infection in perforated peptic ulcer disease is 47% which must be considered as significant. Hence all the patients undergoing laparotomy for peptic ulcer perforation should be investigated for H. pylori infection and if positive we must start the anti H. pylori regimen for them, which is more cost effective.

To err is human: A case-based review of cognitive bias and its role in clinical decision making

To err is human: A case-based review of cognitive bias and its role in clinical decision making

Rapid Source-Control Laparotomy: Is There a Mortality Benefit?

The purpose of this study was to determine the influence rapid source-control laparotomy (RSCL) has on the mortality rate in non-trauma patients with intra-abdominal infection. The hypothesis was that RSCL reduces deaths and hospital lengths of stay (LOS) in patients compared with definitive repair and primary fascial closure (PFC). The International Classification of Diseases-10 codes for sepsis, gastric and duodenal ulcer perforation or hemorrhage, incisional or ventral hernia with obstruction, intestinal volvulus, ileus with obstruction, diverticulitis with perforation or abscess, vascular disorder of intestine, non-traumatic intestinal perforation, peritoneal abscess, and unspecified peritonitis were used to query the 2015 National Surgical Quality Improvement Project (NSQIP) database for all patients treated with either RSCL or PFC. The two groups of patients were compared on the basis of LOS and deaths. Collected data included age, gender, body mass index (BMI), site classification, American Society of Anesthesiologists (ASA) class, operative time, number of risk factors, and pre-operative septic state. After adjusting for the aforementioned variables, propensity score-matched cohorts (n = 210 in each cohort) were used to evaluate the influence of incision closure type on LOS and mortality rate. The odds of death (31.4% vs. 21.4%) with RSCL was 1.78 (95% confidence interval 1.08-2.95; p = 0.02) times that of PFC. Closure type was not significantly associated with an increased LOS (median 14 vs. 11 days; p = 0.35). This retrospective cohort analysis demonstrated that RSCL is associated with higher odds of death in general surgical patients with intra-abdominal infection. There is a need for further studies to delineate what, if any, physiologic parameters indicate a need for RSCL.

Role of Surgeon in the Causation of Surgical Wound Infection in Non-traumatic Emergency Laparotomy

Background: Surgeon has a vital role during operation related with wound infection. Objective: The purpose of the present study was to see the role of wound infection of non-traumatic emergency laparotomy surgeries.Methodology: This descriptive cohort study was carried out in the Department of Surgery at Dhaka Medical College, Dhaka from July 1997 to June 1998 for a period of 1(one) year. Pre-operative patients were carefully assessed for any host factors related to wound infection. Different per-operative factors that influence the rate of postoperative wound infection were also analyzed. Swabs were taken from the suspected postoperative wound and sent for bacteriological examination. The details related to the surgeon were recorded according to their experience.Result: In this series, 100 cases of emergency laparotomies (non-traumatic) were analyzed. Wound infection rate of specific type of operation were 12.5%, 20.0%, 6.6%, 40.0%, 40.0%, 33.3%, 50.0%, 50.0%, and 100.0% in duodenal ulcer perforation, pre-pyloric and gastric ulcer perforation, acute appendicitis, burst appendix, ileal perforation, small intestinal obstruction due to bands and adhesions, volvulus of sigmoid colon, obstructed inguinal hernia, generalized peritonitis due to puerperal sepsis respectively. Surgical site infections are more commonly occur in the operation performed by inexperience younger surgeon (44.4%).Conclusion: The rate of wound infection of non-traumatic emergency laparotomy cases are frequently found in the operation performed by inexperience younger surgeon.Journal of Science Foundation 2016;14(2):52-55

Sugammadex Rescue in Avoiding Intensive Care Unit Admission in an Octogenarian Undergoing Emergency Laparotomy

Postlaparotomy management for elderly patients with underlying comorbidities is always a challenge because of poor cardiorespiratory reserves and prolonged effect of anesthetic drugs. For these reasons, such patients usually require intensive care unit (ICU) admission in the postoperative period. We report a case of an 85-year-old chronic smoker with controlled diabetes mellitus who needed an emergency laparotomy for a perforated gastric ulcer. Unfortunately, there was a shortage of ICU backup. With the successful conduct of an early surgery using combined general and regional anesthesia, the use of sugammadex (Bridion, Merck Sharp & Dohme Corp, Oss, the Netherlands) as a reversal agent, a skilled surgeon, and good postanesthesia care, the patient did not require ICU admission. He recovered fast and was discharged home 4days after surgery. This case study aims to contribute to the literature on experience of a successful conduct of anesthesia in a high-risk geriatric patient when ICU facilities are limited.

Gastric Perforation Caused by an Intragastric Balloon: Endoscopic Findings.

Intragastric balloon (IGB) insertion has been most frequently used in the West as an effective endoscopic treatment for morbid obesity, in practice. Recently, there is a growing number of cases requiring IGB deployment for obesity treatment in Korea. One of the reported complications of IGB use is gastric perforation. A 47-year-old woman was admitted to the hospital with mild symptoms, 7 weeks after having an IGB placed. Esophagogastroduodenoscopy was performed and gastric ulcer perforation was observed in the ulcer base, where food particles were impacted. Laparoscopic primary repair was done successfully. This was a case of gastric perforation, secondary to poor compliance with a proton-pump inhibitor (PPI). PPI and Helicobacter pylori eradication are important for ulcer prevention following IGB deployment.

Endoscopic Management of Gastrointestinal Leaks and Perforation with Polyglycolic Acid Sheets.

Gastrointestinal (GI) leakage, fistulae, and perforations can be serious and life threatening. There has been a paradigm shift in the management approach of these conditions, from surgical to conservative, including endoscopic management. Here, we report two cases of endoscopic closure of a GI fistula and perforation using polyglycolic acid (PGA) sheets with fibrin glue. The first case is of an anastomotic leak detected after subtotal gastrectomy with gastroduodenostomy. After failed application of endoclips, a PGA sheet was applied, and the fistula was successfully closed. The second case was of a 15-mm large perforated gastric ulcer, which was also successfully closed with a PGA sheet. This is the first case report that PGA sheet was used for the treatment of overt perforation. The outcome of these cases suggest that endoscopic closure using PGA sheets can be considered as a useful alternative for the management of GI leakage, fistulae, and perforations.

瘢痕治癒確認 6 日後に潰瘍穿孔を起こした高齢者胃潰瘍の一例

瘢痕治癒確認 6 日後に潰瘍穿孔を起こした高齢者胃潰瘍の一例

Rate of Wound Infection of Non-traumatic Emergency Laparotomy at a Teaching Hospital in Bangladesh: Experience of 100 cases

Background: Wound infection is an important issue for surgical operations. Objective: The purpose of the present study was to measure the rate of wound infection of non-traumatic emergency laparotomy cases.Methodology: This descriptive cohort study was carried out in the Department of Surgery at Dhaka Medical College, Dhaka from July 1997 to June 1998 for a period of 1(one) year. Pre-operative patients were carefully assessed for any host factors related to wound infection. Different per-operative factors that influence the rate of postoperative wound infection were also analyzed. Swabs were taken from the suspected postoperative wound and sent for bacteriological examination. Result: In this series, 100 cases of emergency laparotomies (non-traumatic) were analyzed. Bacteriological examination showed positive culture in most of the cases but three were found to be negative result. Wound infection rate of specific type of operation were 12.5%, 20.0%, 6.6%, 40.0%, 40.0%, 33.3%, 50.0%, 50.0%, and 100.0% in duodenal ulcer perforation, pre-pyloric and gastric ulcer perforation, acute appendicitis, burst appendix, ileal perforation, small intestinal obstruction due to bands and adhesions, volvulus of sigmoid colon, obstructed inguinal hernia, generalized peritonitis due to puerperal sepsis respectively. The overall surgical wound infection rate was 19.0%. Conclusion: The rate of wound infection of non-traumatic emergency laparotomy cases are frequently found in a well-established tertiary care teaching hospital. Bangladesh J Infect Dis 2015;2(1):9-12

Perforated Gastric Ulcer in an Incarcerated Hiatal Hernia

Clinical Imaging; An 81 year male came to our emergency department presenting with dyspnea and chest pain. The chest pain got worse on breathing and radiation to the epigastria. Past medical history included hiatus hernia and hypertension. His blood pressure was 88/63 mmHg, pulse rate 107 per minute. Abdominal examination revealed epigastria tenderness with voluntary guarding. Initial blood tests were all within normal limits. Chest X-ray revealed hiatal hernia with gas distension of the stomach (Figure 1A). Abdominal X-ray showed no diagnostic features. The abdomen CT reveals upper abdomen pneumoperitoneum in the periportal space and hernia sac (Figure 1B), moderate amount of ascites are also noted suspect gastric juice leakage (Figure 1C), indicating perforated gastric ulcer. He was taken for emergent exploratory laparotomy immediately .The right posterior wall fundus of gastric ulcer perforation 2 × 2 cm and upper gastric incarceration hiatal hernia were noted. The hiatal hernia repair and perforated ulcer repair were done. The patient recovered smoothly and was discharged 3 weeks later. Perforated gastric ulcer in an Incarcerated hiatal hernia is rare and the diagnosis is challenge. CT is the gold standard diagnostics and early surgery intervention reduces mortality and consequent complication.

Posterior perforation of gastric ulcer: A rare surgical emergency

BACKGROUND:Gastric ulcer perforation is a rare surgical emergency.Posterior gastric ulcer is even rarer and usually has a delayed presentation with attendant greater morbidity and mortality.AIM:To report a case of posterior perforation of gastric ulcer and review the literature.CASE REPORT:A 65yr old driver was seen in the hospital with a 4- day history of epigastric pain which became generalized. Examination revealed a patient in shock with a board-like rigidity of the abdomen. Chest x-ray confirmed pneumoperitoneum. He had an exploratory laparotomy. Findings at surgery include moderate peritoneal fluid collection and 1.5cm diameter perforation on the posterior gastric wall which was closed primarily with an omental patch. Biopsy of the ulcer edge was negative for malignancy. He was discharged 10 days after surgery.CONCLUSION:To the best of our knowledge,perforation of a posterior gastric ulcer is an unusual encounter in surgery.A high index of suspicion is needed to prevent high mortality.KEY WORDS: Posterior,Gastric,Rare,Ulcer.

Surgical Scales: Primary Closure versus Gastric Resection for Perforated Gastric Ulcer - A Surgical Debate.

Perforated gastric ulcer is one of the most life-threatening complications of peptic ulcer disease with high morbidity and mortality rates. The surgical strategy for gastric perforation in contrast with duodenal perforations often requires consilium and intraoperative debates. The subject of the debate is a 59-year-old male patient who presented with perforated giant gastric ulcer complicated by generalized peritonitis and severe sepsis. The debate is based on a systematized table dividing all factors into three groups and putting them on surgical scales. Pathology-related factors influencing the decision-making are size and site of perforation, local tissue inflammation, signs of malignancy, simultaneous complications of peptic ulcer, peritonitis, and sepsis. Besides these factors, patient- and healthcare-related factors should also be considered.

Valentino's syndrome: An unusual presentation of a perforated peptic ulcer

Valentino's syndrome occurs when digestive fluids tend to settle in the right iliac fossa through a perforated gastric or duodenal ulcer, causing peritonitis and clinically mimicking acute appendicitis. Herein, we present the case of a 32-year-old male who was admitted to the emergency department with signs and symptoms suggestive of acute appendicitis. During laparoscopic appendectomy, inspection of the peritoneal cavity revealed an anterior, perforated duodenal ulcer, which was treated with a patch repair. The patient's recovery was uneventful, and a gastrointestinal endoscopy at his 6-week follow-up showed complete healing of the ulcer. This case highlights that Valentino's syndrome should be considered in the differential diagnosis of any patient who has an abdominal examination consistent with acute appendicitis.

Surgeons beware: It may not be acute appendicitis

Acute appendicitis may mimic several acute abdominal conditions. In perforated peptic ulcer disease, the contents may track down the right iliac fossa to mimic the presentation of acute appendicitis. The objective of this study was to highlight the diagnostic dilemma encountered in differentiating perforated peptic ulcer (with gastric contents tracking into the right iliac fossa) and acute appendicitis. We present the case of a 45-year old man who had appendicectomy in a private medical center and later developed features of generalized peritonitis 10 days after surgery. Following a diagnosis of postoperative peritonitis, exploratory laparotomy was carried out, which revealed perforated gastric ulcer. The perforation was repaired and peritoneal lavage was done. He made an uneventful recovery and was discharged after 3 weeks on admission. Perforated peptic ulcer could mimic acute appendicitis. A high index of suspicion is vital in differentiating both conditions, to prevent the morbidity and mortality resulting from misdiagnosis.

Perforated Benign Giant Gastric Ulcer in a Young Patient: A Rare Entity

A 33 year old lady presented to our Accident and Emergency (A&E) department with acute onset epigastric pain that became generalised with vomiting and fever. History revealed chronic habitual use of ‘over the counter’ (OTC) non-steroidal anti-inflammatory drug (NSAID), Neurofen Plus for chronic shoulder pain and significant smoking habit. Clincal examination showed severe dehydration with evidence of sepsis and haemodynamic instability. There was a generalised abdominal tenderness with guarding. A diagnosis of acute abdomen with generalised peritonitis due to a suspected perforated viscus was made. An urgent CT scan showed free peritoneal air and fluid. She was transferred directly from the resuscitation room to the operating theatre and underwent an emergency laparotomy and closure of perforated giant gastric ulcer measuring 4cm x 3 cm in size. This case of rare giant perforated benign gastric ulcer in a young patient highlights the importance of early recognition of the risk factors such as the chronic use of NSAIDs in peptic ulcer disease and its complication.

Les Perforations D’ulcere Gastro-Duodenal Au Centre National Hospitalier Et Universitaire (Cnhu) De Cotonou (Benin)

Introduction: Duodenal or gastric ulcer perforations constitute a medical and surgical emergency. Purpose: Expose its epidemiological, diagnostic and therapeutic aspects. Method: About a retrospective study from January 1st 2006 to March 31st, 2012 in visceral surgery at CNHU of Cotonou, records of 86 cases of duodenal or gastric ulcer perforation were analyzed. Results: On average 13.8 cases / year, perforation of peptic ulcer was the most etiological cause of acute generalized peritonitis (25.7%). The average age was 34.2 years, the sex ratio of 16.2. Average admission stay was 6 days and it was observed: undocumented epigastralgia (42cas; 48.8%), no pathological medical history (32 cases; 37.2%). Peritoneal syndrome was in 81 cases (94.2%). Abdomen radiography without preparation (71 patients / 86; 82.6%) showed a pneumoperitoneum (52 cases / 71; 77.6%). The treatment was nonoperative (2 cases / 86; 2.3%) with a favorable outcome. Surgical patients had duodenal perforation (49 cases / 84; 57%), gastric perforation (35 cases / 84; 43%). Suturing with or without other technical devices was achieved in all cases. Postoperative complications were present in 28.5% of cases and parietal abscesses were documented as a priority (14 cases / 84; 16.7%). Mortality rate was 4.7% (4/86) and the average hospital stay was 11.6 days. Conclusion: The perforations of peptic ulcer were common in young men. Clinical examination was especially helpful in the diagnosis by abdomen radiography without preparation. The treatment was medical and surgical and the outcome was mostly favorable.

Non-operative Treatment of Gastric Ulcer Perforation with Contrast Leakage in an Elderly Patient

여러 문헌을 고찰해 볼 때, 활력 징후가 정상이고, 젊은 환자의 경우에는 비수술적 치료를 고려해 볼 수 있지만 오진의 가능성이나, 비수술적 치료 도중 수술적 치료로 전환되었을때의 부담감 등의 이유로 비수술적 치료를 우선적으로 선택하기에는 여전히 어려움이 있을 것으로 보인다. 본 증례의 환자는 고령이면서, 복막자극 징후를 동반한 위궤양 천공이 진단되어 비수술적 치료의 실패 가능성이 매우 높았지만 이전의 문헌에서 사용했던 소화성 궤양 천공의 보존적 치료 방법을 유지하여 성공적으로 치유되었다. 고령의 소화성 궤양 천공 환자에서 내과적인 치료만을 원하는 경우라도 성급하게 치료 실패를 예단하기보다 적극적인 관리를 통해 성공적인 치유를 기대할 수 있다는 가능성을 보고하고자 증례를 작성하였다.

Asymptomatic Gastric Band Erosion Detected during Routine Gastroduodenoscopy.

The incidence of gastric band erosion has decreased to 1%. Gastric band erosion can manifest with various clinical symptoms, although some patients remain asymptomatic. We present a case of a mostly asymptomatic patient who was diagnosed with gastric band erosion during a routine health check-up. A 32-year-old man without any underlying diseases except for non-alcoholic fatty liver underwent laparoscopic adjustable gastric band surgery in 2010. He had no significant complications postoperatively. He underwent routine health check-ups with near-normal gastroduodenoscopic findings through 2014. However, in 2015, routine gastroduodenoscopy showed that the gastric band had eroded into the stomach. His gastric band was removed laparoscopically, and the remaining gastric ulcer perforation was repaired using an omental patch. Due to the early diagnosis, the infection was not serious. The patient was discharged on postoperative day 3 with oral antibiotics. This patient was fortunately diagnosed early by virtue of a routine health check-up; thus, eliminating the possibility of serious complications.

Observational study of laparoscopic closure of peptic ulcer perforation in rural population

Background: Peptic ulcer perforation is one of the common surgical emergencies which need immediate surgical intervention. For many years, the routine upper laparotomy still seems to be the routine treatment of perforated peptic ulcer. The improvement of technology and an increase in laparoscopic experience have been central to the development of laparoscopic surgery. Objective of the study was to assess the efficacy of laparoscopic approach in perforated peptic ulcer repair. Methods: The present study is based on the analysis of 30 cases of peptic ulcer perforation admitted to our hospital between 2013 and 2015. Post-operative mobilization of every patient was done after 6 hours and H 2 receptor antagonist or proton pump inhibitor was given with fluid, antibiotics and nasogastric suction. Post-operation analgesics (IV tramadol ± IM diclofenac SOS) were given according to visual analogue score (VAS). Results: 22 (73.33%) patients were having duodenal ulcer perforation and 8 (26.67%) were having gastric ulcer perforation. Postoperatively out of 30 patients, 18 patients were presented with VAS 4. The most common complication was trocar site infection seen in 2 patients (6.6%). 3 patients (10%) needed to covert laparoscopic procedure into open procedure due to large size of perforation (>10 mm). The hospital stay varied from 4-16 days. Conclusions: Laparoscopic repair of perforated peptic ulcer is safe and reliable technique. It gives the patient all the advantages of laparoscopic surgery with accepted post-operative morbidity and mortality rates. However, laparoscopic closure of the perforation is technically demanding. It should be considered as a good choice in the presence of reasonable laparoscopic skills and experience. It had less postoperative pain and reduced analgesic usages, shorter postoperative hospital stay and early return to oral feeding and normal daily activities.