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Acute Perforated Duodenal Ulcer Is Not Associated with Helicobacter Pylori Infection

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Acute Perforated Duodenal Ulcer Is Not Associated with Helicobacter Pylori Infection 1344 Gutl993;34:1344-1347 Acute perforated duodenal ulcer is not associated with Helicobacterpylori infection Gut: first published as 10.1136/gut.34.10.1344 on 1 October 1993. Downloaded from D H Reinbach, G Cruickshank, K E L McColl Abstract infection in patients having a laparotomy for Most patients with chronic duodenal ulcer repair of a perforated duodenal ulcer. disease have Helicobacterpylori infection and eradicating it considerably reduces the relapse rate. The prevalence ofHpylon in 80 patients Patients and methods (mean age=52 years, range 17-85) presenting Over a one year period, patients presenting with with acute perforated duodenal ulcer was a perforated duodenal ulcer were recruited from examined and compared with age and sex seven hospitals in the Glasgow area, covering a matched hospital control patients. H pylon population of approximately one million. All state was assessed by serum anti-Hpylon IgG patients were identified by regular contact with (Helico-G kit, Porton) using a titre of 18 or less the Emergency Theatre departments of each as negative with a specificity of 89% and hospital. The patients were visited during their sensitivity of 88%. Only 47% of the perforated hospital stay, usually between days 3-5 after duodenal ulcer patients were positive for operation. The operation notes were examined H pylon and this was similar to the value of (by DHR) and only those patients identified as 50% in the controls. In 51 of the perforated having perforation of a duodenal ulcer were duodenal ulcer patients '4C-urea breath tests included. Patients with perforation of prepyloric were also performed 4-10 weeks after surgery or gastric ulcers were excluded. and this confirmed that only 49% were positive After informed consent was obtained, the for H pylon. None of these patients had following details were recorded: age, sex, past received perioperative drugs that might have medical history, past history of ulcer disease, eradicated the infection. The Hpylori positive history of dyspepsia, drug history, smoking and and H pylon negative perforated duodenal drinking habits, family history, and drugs given ulcer patients were similar with respect to age during hospital stay. A patient was only con- http://gut.bmj.com/ (53, 51), smoking (84%, 83%), and consump- sidered to have a past history of duodenal ulcer tion of more than 15 units of alcohol per week disease if an active ulcer or deformed duodenum (42%, 38%). Duodenal ulcer disease had been had been shown previously by barium meal or diagnosed before acute perforation in only 24% endoscopy or at previous laparotomy. A patient of those with H pylori and also 24% of those was considered to have a history of dyspepsia without the infection. Regular non-steroidal if they had experienced intermittent upper anti-inflammatory drug (NSAID) use was com- abdominal pain with some relation to eating. on September 30, 2021 by guest. Protected copyright. mon in both those with (44%) and without Information was also obtained from the (45%) H pylori. In conclusion, the lack of operation notes or speaking to the surgeon who association of acute perforated duodenal ulcer performed the procedure, or both to ascertain and Hpylon infection suggests that perforated whether the perforated ulcer had the appearance duodenal ulcer has a different pathogenesis of an acute or chronic ulcer. from chronic duodenal ulcer disease, and that Within five days of the patients admission for the first should not be regarded simply as a acute perforated duodenal ulcer, 30 ml of complication ofthe second. venous blood was taken for H pylori serology. (Gut 1993; 34:1344-1347) This was allowed to clot and then centrifuged and the serum stored at -20°C. As a further means of assessing H pylori state, patients were Helicobacter pyloni infection of the antral mucosa requested to attend for a '4C-urea breath test at plays an important part in the pathogenesis of the Western Infirmary, Glasgow. This was per- chronic recurrent duodenal ulceration. More formed at least four weeks after both discharge than 95% of such have the infection and and withdrawal from any drugs. On that University Departments patients of Surgery, Medicine and eradicating it considerably reduces the ulcer occasion a further blood sample was obtained Therapeutics, and recurrence rate.'13 The role of H pylon infection from these patients for repeat H pylori serology. Immunopathology, in chronic duodenal ulcer disease may be For control purposes, serum samples were Western Infinnary, Glasgow explained by the fact that it causes excessive obtained for H pylori serology from 80 age and D H Reinbach release of gastrin by the antral mucosa, sex matched patients admitted to one of the G Cruickshank which in turn stimulates excessive acid hospitals. This serum was again obtained within K E L McColl secretion.4 two days of admission and those patients suf- Correspondence to: a range medical and Dr K E L McColl, Although the role of H pylorn in the patho- fered from wide of surgical Department of Medicine and genesis of chronic duodenal ulcer disease is now conditions. Therapeutics, Western well established, its importance in acute per- Studies were also performed to exclude the Infirmary, Glasgow GIl 6NT. that interfere with Accepted for publication forated duodenal ulcer is unknown. The aim of possibility laparotomy might 16 February 1993 this study was to assess the prevalence ofHpyloni the serology test for H pylori infection. This was Acuteperforated duodenal ulcer is not associated with Helicobacter pylori infection 1345 TABLE I Details ofthe three patients who had recurrent perforations postoperative death, refusal to sign a consent form, or inability to sign it on account of mental Time interval betveen H pylori confusion. Consequently, 80 patients were Sex Age perforations Drug treatment Alcohol Smoker state enrolled into the study. Their mean age was 52 Gut: first published as 10.1136/gut.34.10.1344 on 1 October 1993. Downloaded from Male 39 12 years Regular H2 < 10 units/week Yes Positive years (range 17-85) and 59 (74%) were men. antagonists Three (4%) were taking steroids and 35 (44%) Female 61 5 years Intermittent H2 None Yes Positive antagonists NSAIDs. Sixty seven (84%) of the patients Male 49 6 months Regular H2 >20 units/week Yes Positive smoked and 32 (40%) drank more than 15 units antagonists of alcohol per week. Twenty one (26%) had a family history of ulcer disease. Only 19 (24%) had a past history of ulcer disease and only 31 done by obtaining serum samples from three (39%) had a history of dyspepsia for more than patients obtained before and five days after three months. Eighteen (22%) had been on acid surgery. inhibitory treatment at the time of perforation and only a further 10 (13%) had previously had acid inhibitory treatment. ANALYSES Two of the patients had experienced a pre- H pylori serology was performed using a com- vious perforation, which had been treated by mercial IgG ELISA kit (Helico G serology simple closure and omental patch. A further kit, Porton, Cambridge, UK). This has been patient who presented with his first perforation validated in our own hospital and with a titre of in this study and was treated with simple closure 18 IU/ml or less as negative, has a sensitivity of and omental patch presented with a further 88% and specificity of 89%. perforation of duodenal ulcer six months later. The '4C-urea breath test was performed as Only his first presentation was included in the previously described.5 This has also been analysis. Table I gives further details of these validated in our own unit and using a 20 minute three patients. value of >20 (percentage 14C dose per mmol In 71 of 80 patients, the surgeon considered CO2x lOOxkg body wt) as positive has a the perforation to be acute and in only nine was it sensitivity and specificity of >95%. The study considered to be a perforation against a back- was approved by the Western Infirmary Ethical ground of chronic duodenal ulceration. All Committee. patients except three were treated surgically by simple closure and omental patch. Because of a history of chronic duodenal ulceration, one Results patient, a 39 year old man, had a vagotomy and One hundred and eleven patients were identified pyloroplasty, and one patient, a 55 year old man, with acute perforated duodenal ulcer during the a vagotomy and gastroenterostomy. The third, a http://gut.bmj.com/ 12 months ofthe study. Thirty one of those were 75 year old man, had a polya partial gastrectomy unsuitable for entry to the study because of early because of technical difficulties in oversewing his chronic duodenal ulcer. Anti-Hpylori IgG serology performed in these 0 130 * 130 * 130 80 patients during their admission for acute 0 115 0 1 1 0 0 1 1 0 * 1 1 0 duodenal ulceration showed that 47% were 0 95 0100 positive and 53% negative (Fig 1). Each of the on September 30, 2021 by guest. Protected copyright. 70 three patients with recurrent perforation were 65 - 0 positive for H pylori. Fifty one patients attended 0 0 for a '4C urea breath test and by this 49% were 60 - positive and 51% negative (Fig 2). The patients *0 55 - who attended for the breath test were represen- tative of the entire 80 patients studied, having a 50 - mean age of 50 years (range 19-85) and 82% E 45 - 00 being men. Only five of these patients who attended for the breath test had received drugs 40 - 0.0 0 for than 24 hours after their 0.0 longer perforation - and there was no association of perioperative 35 0 Z: treatment and subsequent breath test result 0.
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