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Perforated Peptic Ulcer in Khartoum State

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Perforated Peptic Ulcer in Khartoum State ﺑﺴﻢ ﺍﷲ ﺍﻟﺮﲪﻦ ﺍﻟﺮﺣﻴﻢ UNIVERSITY OF KHARTOUM Faculty of Medicine Postgraduate Medical Studies Board Perforated peptic ulcer in Khartoum state By Dr. Al Fatih Mohamed Ahmed Alnajib M.B.B.S (University of Gezira) A thesis Submitted in partial fulfillment for the requirements of the Degree of Clinical MD in Surgery, October, 2002 Supervisor Prof. Mohamed El Makki Ahmed MS, FRCSI, Professor of Surgery ﺑﺴﻢ ﺍﷲ ﺍﻟﺮﲪﻦ ﺍﻟﺮﺣﻴﻢ ﻗﺎﻝ ﺍﷲ ﺗﻌﺎﻟﻰ : } ﻗﺎﻟﻮﺍ ﺳﺒﺤﺎﻧﻚ ﻻ ﻋﻠﻢ ﻟﻨﺎ ﺇﻻ ﻣﺎ ﻋﻠﻤﺘﻨﺎ ﺇﻧﻚ .{ ﺃﻧﺖ ﺍﻟﻌﻠﻴﻢ ﺍﻟﺤﻜﻴﻢ ﺻﺪﻕ ﺍﷲ ﺍﻟﻌﻈﻴﻢ CONTENTS Page Dedication I Acknowledgements II List of abbreviations III English abstract IV V Arabic abstract VI List of tables VIII List of figures CHAPTER ONE 1 Introduction and Literature review Objectives 25 CHAPTER TWO Patients & Methods 26 CHAPTER THREE Results 28 CHAPTER FOUR Discussion 58 Conclusion 65 Recommendations 67 References 68 APPENDIX Questionnaire 69 APACHE II Score 73 Dedications To my parents, teachers, Sisters & brothers ACKNOWLEDGEMENT I will always feel indebted to my supervisor Prof. Mohamed El Makki Ahmed, Professor of surgery, Faculty of Medicine, University of Khartoum, for his kind and meticulous supervision, encouragement, and guidance in this work with great patience from it’s beginning to the final touches. I would also like to express my sincere thanks and gratitude to my colleagues the registrars of surgery and the house officers who help a lot in data collection, their indefatigable efforts and cheerful co-operation are without parallel. Special thanks for all those helped or participated in this work to come to the light, not forgetting to thank Miss. Widad for help in typing and Mr. Hassan for the data analysis. ABBREVIATIONS APACHE Acute physiology and chronic health evaluation CXR Chest X-ray COX Cyctooxygenase DU Duodenal ulcer GU Gastric ulcer H2 receptors Histamine 2 receptors H. pylori Helicobacter pylori PPI Proton pump inhibitor PPU Perforated peptic ulcer ZES Zollingar Ellesions Syndrome PUD Peptic ulcer disease ABSTRACT Background: Although perforated peptic ulcer (PPU) is evaluated in different parts of the World, no study was held to evaluate the disease in Sudan. This study aimed to evaluate the incidence, clinical presentation, management and outcome of perforated peptic ulcer. Methods: Data from 58 consecutive patients with PPU was collected and analysed in the period between November 1999 and April 2002. Fifty-two (89.6%) were male patients and six (10.4%) females. Results: Twenty-five (43.1%) of the studied group were below 30 years of age, only 10(17.2%) were known cases of peptic ulcer disease. Twenty-two (40%) of perforations occurred during the month of Ramadan and most of the patients were fasting 20(34.4%). Forty-two (72.4%), of the total number of patients, presented during the winter season. Fifty- three (91.3%) were perforated duodenal ulcers and three (5.2%) were perforated gastric ulcers. Fifty-five (94.8%) had surgical treatment, 53(91.3%) patients had simple closure with omental patch. Postoperative complications occurred in 18 (31%) patients and there were seven (12%) deaths. The most significant factors for both morbidity and mortality were old age group, late presentation, concomitant medical illness, size of perforation more than two cm and shock on presentation. Conclusion: PUP predominantly occurred in young age group as compared to International data and most of the patients were not known to suffer from peptic ulcer disease. The incidence increased in winter season and during fasting. ﻤﻠﺨﺹ ﺍﻷﻁﺭﻭﺤﺔ ﺗﻘﺪﱘ: ﱂ ﻳﺘﻢ ﺗﻘﻴﻴﻢ ﺍﻧﻔﺠﺎﺭ ﺍﻟﻘﺮﺣﺔ ﺍﳍﻀﻤﻴﺔ ﻣﻦ ﻗﺒﻞ ﰱ ﺍﻟﺴﻮﺩﺍﻥ، ﺃﺟﺮﻳﺖ ﻫﺬﻩ ﺍﻟﺪﺭﺍﺳﺔ ﻟﺘﺴﻠﻴﻂ ﺍﻟﻀﺆ ﻋﻠﻰ ﺍﳊﺪﻭﺙ ﻭﺍﺠﻤﻟﻰﺀ ﺍﻟﺴﺮﻳﺮﻱ، ﺍﳌﻌﺎﳉﺔ ﻭﺍﻟﻨﺎﺗﺞ. ﺍﻟﻔﻜﺭﺓ: ﺘﻡ ﺘﺠﻤﻴﻊ ﺍﻟﻤﻌﻠﻭﻤﺎﺕ ﻋﻥ ﺜﻤ ﺎﻨﻴﺔ ﻭﺨﻤﺴﻴﻥ ﻤ ﺭ ﻴ ﻀ ﺎﹰ ﻋﻠﻰ ﺍﻟﺘﺘﺎﻟﻲ ﻤﺼـﺎﺒﻴﻥ ﺒﺎﻟﻘﺭﺤـﺔ ﺍﻟﻬﻀﻤﻴﺔ ﺍﻟﻤﻨﻔﺠﺭﺓ ﻭﻤﻥ ﺜﻡ ﺘﻡ ﺘﺤﻠﻴﻠﻬﺎ. ﺍﻟﻨﺘﺎﺌﺞ: ﻤﻥ ﺸﻬﺭ ﻨﻭﻓﻤﺒﺭ ﻋﺎﻡ 1999ﻡ ﻭﺤﺘﻰ ﻤﺎﺭﺱ 2002ﻡ، ﺤﻀﺭ 52 ﺫﻜﺭ ﻭﺴﺕ ﺇﻨﺎﺙ ﻤﺼﺎﺒﻭﻥ ﺒﺈﻨﻔﺠﺎﺭ ﺍﻟﻘﺭﺤﺔ ﺍﻟﻬﻀﻤﻴﺔ. ﺃﻜﺜﺭ ﺍﻷﻋﻤﺎﺭ ﺘ ﺄ ﺜ ﺭ ﺍﹰ ﻫﻡ ﻤﺎ ﺩﻭﻥ ﺍﻟﺜﻼﺜﻴﻥ ﺴﻨﺔ . ﻋﺸﺭﺓ ﻤﺭﻀﻰ ﻓﻘﻁ ﻜﺎﻨﻭﺍ ﻤﻌﺭﻭﻓﻴﻥ ﺍﻹﺼﺎﺒﺔ ﺒﻤﺭﺽ ﺍﻟﻘﺭﺤﺔ ﺍﻟﻬﻀﻤﻴﺔ ﻗﺒل ﺤﺩﻭﺙ ﺍﻹﻨﺜﻘﺎﺏ، 40% ﺘﻘﺭﻴﺒﹰﺎ ﻤﻥ ﺠﻤﻠﺔ ﺤﺎﻻﺕ ﺍﻹﻨﺜﻘﺎﺏ ﺤـﺩﺜﺕ ﺨـﻼل ﺸﻬﺭ ﺭﻤﻀﺎﻥ "ﻋﺩﺩ 22 ﻤﺭﻴﺽ ". ﻜﺎﻥ ﻤﻌﻅﻡ ﺍﻟﻤﺭﻀﻰ ﺼﺎﺌﻤﻴﻥ "ﻋﺩﺩ 20 ﻤﺭﻴﺽ "، 42(24.7%) ﻤﻥ ﺤﺎﻻﺕ ﺇﻨﻔﺠﺎﺭ ﺍﻟﻘﺭﺤﺔ ﺤﺩﺜﺕ ﺨﻼل ﺍﻟﺸﺘﺎﺀ . 53(96.4%) ﻤﻥ ﺍﻟﺤﺎﻻﺕ ﻜﺎﻨﺕ ﻗﺭﺤـﺔ ﺍﻷﺜﻨـﻲ ﻋﺸـﺭ، ﻭﺜﻼﺙ ﻤﻥ ﺍﻟﺤﺎﻻﺕ ﻜﺎﻨﺕ ﻗﺭﺤﺔ ﺍﻟﻤﻌﺩﺓ . ﻜل ﺍﻟﻤﺭﻀﻰ ﺘﻘﺭﻴﺒﹰﺎ "ﻋﺩﺩ 55" ﺘﻤﺕ ﻤﻌﺎﻟﺠﺘﻬﻡ ﺠ ﺭ ﺍ ﺤ ﻴ ﺎﹰ ﺒﻭﺍﺴﻁﺔ ﺍﻟﻘﻔل ﺍﻟﺒﺴﻴﻁ ﻤﻊ ﺭﻗﻌﺔ ﺍﻟﺜﺭﺏ . ﻤﻀﺎﻋﻔﺎﺕ ﺒﻌﺩ ﺍﻟﻌﻤﻠﻴﺔ ﺤﺩﺜﺕ ﻓﻰ 17 (31.8%) ﻜﻤﺎ ﺃﻥ ﻫﻨﺎﻟﻙ ﺴـﺒﻌﺔ ﺤﺎﻻﺕ ﻭﻓﺎﺓ. ﺍﻟﻌﻭﺍﻤل ﺍﻷﻜﺜﺭ ﺇﻋﺘﺒﺎﺭﻴﺔ ﻤﻥ ﺤﻴﺙ ﺍﻟﻤﺭﺍﻀﺔ ﻭﺍﻟﻭﻓﺎﺓ ﻜﺎﻨﺕ، ﻜﺒﺭ ﺍﻟﺴﻥ، ﻋﻨﺼـﺭ ﺍﻟﻨﺴـﺎﺀ ، ﺍﻟﺤﻀﻭﺭ ﺍﻟﻤﺘﺄﺨﺭ، ﻭﺠﻭﺩ ﻤﺭﺽ ﻤﻌﺎﺼﺭ، ﺤﺠﻡ ﺍﻟﺜﻘﺏ ﺍﻜﺜﺭ ﻤﻥ 2 ﺴﻡ، ﺍﻟﺼﺩﻤﺔ ﺍﻟﺩﻭﺭﺍﻨﻴﺔ ﻋﻨﺩ ﺍﻟﺤﻀﻭﺭ ﺒﺎﻹﻀﺎﻓﺔ ﺇﻟﻰ ﻨﻘﺹ ﺍﻟﺼﻭﺩﻴﻭﻡ ﻭﺍﻟﺒﻭﺘﺎﺴﻴﻭﻡ. ﺍﻟﺨﻼﺼﺔ: ﻴﺒﺩﻭ ﺃﻥ ﺍﻨﻔﺠﺎﺭ ﺍﻟﻘﺭﺤﺔ ﺍﻟﻬﻀﻤﻴﺔ ﻤﺭﺽ ﻴﺼﻴﺏ ﺍﻟﺸﺒﺎﺏ ﻏ ﺎ ﻟ ﺒ ﺎﹰ ﻟﻴﺴـﻭﺍ ﻤﺭﻀـﻰ ﻤﻌﺭﻭﻓﻴﻥ ﺒﺎﻟﻘﺭﺤﺔ ﺍﻟﻬﻀﻤﻴﺔ ﻭﺘﺯﻴﺩ ﺤﺎﻻﺕ ﺍﻟﺤﺩﻭﺙ ﻓﻰ ﻓﺼل ﺍﻟﺸﺘﺎﺀ ﻜﻤﺎ ﻭﺃﻥ ﺍﻟﺼـﻴﺎﻡ ﻴﺒـﺩﻭ ﻜﻤﺤﻔـﺯ ﻟﺤﺩﻭﺙ ﺍﻻﻨﻔﺠﺎﺭ. INTRODUCTION Peptic ulcer perforation (PUP) occurs in about 10% of patients with peptic ulcer disease. (1) It is the commonest perforation of the upper gastrointestinal tract. Being a life threatening complication of Peptic ulcer disease (PUD) it needs prompt resuscitation and appropriate surgical management, if mortality and morbidity are to be avoided. It is the deep penetrating ulcers in the anterior surface of the duodenum and stomach that usually perforate in the peritoneal cavity. (2) Posterior surface lesions usually penetrate into the pancreas and present as bleeding rather than free perforation. A revolution in both diagnosis and management of PU disease occurred in the last few decades namely the H. pylori relations to the disease together with H2 receptor antagonists and PPI remedies and improvement in endoscopic facilities. In spite of all these, the incidence of PUP seems to be unaffected,(3) the thing which could be attributed to NSAIDs ingestion. ¾ Anatomy: The stomach lies in the left upper quadrant crossing the midline at the pylorus. The most proximal part is the cardia, small area, just distal to the GOJ. Populated by mucus gland cells. The corpus is the largest portion, lies between the cardia and antrum. It contains mucus, parietal and chief cells, the last two secrete acid and pepsin respectively. The antrum separated from the corpus by the incisura in the lesser curvature and the point where the left gastroepiploic artery enter the stomach along the greater curvature. Its populated by G- cells which secret gastrin which important in regulation of gastric acid secretion. The pylorus has strong muscles; it pumps the gastric contents into the duodenum. Blood supply: The left gastric artery is the largest artery supplying the stomach. It arises from the celiac trunk and runs a long the lesser curvature. The right gastric artery, from the common hepatic. The right gastroepiploic artery from the gastroduodenal artery, courses a long the greater curvature from right to left. The left gastroepiploic artery, a branch from the splenic artery, supplies the greater curvature of the fundus. The duodenum is supplied in it is superior part by the superior pancreaticoduodenal artery, a branch of gastroduodenal artery. The inferior part is supplied by the inferior pancreato-duodenal artery, a branch of the superior mesenteric artery. The stomach and duodenum have extensive submucosal channels that ensure a rich blood supply to the mucosa. This ensures adequate blood supply to the stomach even if only one of the four major vessels is intact. Venous drainage is through coronary, gastroepiploic and splenic vein to the portal vein.(4) Nerve supply: The stomach is supplied by the two major vagal trunks. The largest is the posterior, which is closely adherent to intra-abdominal oesophagus and slightly to the left of the midline. It’s large and easily identified during surgery. The anterior vagus resides slightly to the right of the intraabdominal oesophagus, it’s much smaller than the anterior and more difficult to localize. The nerve of Grassi is a branch of the posterior vagus that innervates the fundus. Failure to ligate this branch may result in ulcer recurrence following vagotomy. The nerves of Laterjet (Crow’s foot) are a tangle of nerves, Branches from the main trunks at the incisura. They innervate the antrum (5) and must be spared in highly selected vagotomy. ¾ Physiology: Acid secretion: Acid secretion occurs in the gastric corpus and fundus by the parietal cells. These cells secrete acid against very high concentration gradients. The maximum luminal acid concentration is 0.15N so acid concentration is more than ten million times the concentration of hydrogen in the blood. Acid in this concentration is highly corrosive and would disintegrate any tissue coming into contact. The stomach has several protective mechanisms against acid digestions; The tight intercellular junctions prevent luminal acid from penetrating the gastric epithelium; The luminal bicarbonate secretion, for each acid molecule generated a molecule of bicarbonate ion is secreted. Although most of it is carried away by gastric blood flow, some is secreted into the thick mucus gel. It also has a thick alkaline mucus gel lies immediately adjacent to the gastric epithelium, protecting it from injury. There is also a net outward fluid flux into the lumen which must exist with both acid and bicarbonate, this flux of water has a greater ability to maintain the gradient than any amount of mucus or bicarbonate. Because of the constant exposure to very high concentration of acid, gastric ulceration is unrelated to acid production. The primary responsible mechanism is the loss of gastric epithelial protective mechanism.(2,5) Signals of gastric acid secretion: Vagal activation: Stimulates secretion by several mechanisms; the release acetylcholine in the immediate vicinity of parietal cell. This cholinergic stimulation results in increase intracellular calcium of the parietal cells which leads to acid secretion. Stimulation of antral interneurons to release gastrin releasing peptide "GRP", which stimulates antral G.
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  • [ ​Color Index​ | ​ Important​ | ​Notes​ ​ | ​Extra​ ]
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