Original Article Perforated Peptic Ulcer: Different Ethnic, Climatic and Fasting Risk Factors for Morbidity in Al-Ain Medical District, United Arab Emirates Fawaz Chikh Torab, Mohamed Amer, Fikri M. Abu-Zidan and Frank James Branicki, Department of Surgery, Faculty of Medicine & Health Sciences, UAE University, UAE. AIM: To evaluate risk factors, morbidity and mortality rates of perforated peptic ulcer (PPU) and to inves- tigate factors affecting postoperative complications of PPU. BACKGROUND: The incidence of PPU has remained constant, simple closure with omental patch repair being the mainstay of treatment. PATIENTS AND METHODS: One hundred and nineteen patients admitted to Al-Ain Hospital with PPU between January 2000 and March 2004 was studied retrospectively; two with deficient data were excluded from the analysis. Logistic regression was used to define factors affecting postoperative complications. RESULTS: The mean age of patients was 35.3 years (range, 20–65). 45.7% of patients were Bangladeshi, and 85.3% originated from the Indian subcontinent. One patient, subsequently found to have a perfo- rated gastric cancer, died. In 116 patients, 26 complications were recorded in 20 patients (17.2%). Common risk factors for perforation were smoking, history of peptic ulcer disease (PUD) and use of non-steroidal anti-inflammatory drugs (NSAIDs). A significantly increased risk of perforation was evident during the daytime fasting month of Ramadan. An increase in the acute physiology and chronic health evaluation (APACHE) II score (p = 0.047) and a reduced white blood cell count (0.04) were highly significant for the prediction of postoperative complications. CONCLUSION: Patients with dyspeptic symptoms and a history of previous PUD should be considered for prophylactic treatment to prevent ulcer recurrence during prolonged daytime fasting in Ramadan, especially during the winter time. [Asian J Surg 2009;32(2):95–101] Key Words: peptic ulcer, perforation Introduction e.g. smoking,3 NSAID use, a previous history of PUD, Helicobacter pylori infection4 and alcohol intake have dif- Although morbidity from peptic ulcer disease (PUD) ferent prevalence rates in differing communities and is decreasing in the west, the incidence of perforated affect the incidence of perforation in various ways with ulcer remains relatively constant.1,2 Perforated ulcers are additive effects of multiple factors.5–7 We observed in our decreasing in incidence in younger age patients and practice different epidemiological characteristics of pep- are increasingly being observed in the elderly and in tic ulcer perforation other than those evident in western women.1,2 Different risk factors for PUD and perforation societies. Address correspondence and reprint requests to Professor Frank James Branicki, Department of Surgery, Faculty of Medicine & Health Sciences, United Arab Emirates University, P.O. Box 17666, Al-Ain, United Arab Emirates. E-mail: [email protected] ● Date of acceptance: 5 December 2008 © 2009 Elsevier. All rights reserved. ASIAN JOURNAL OF SURGERY VOL 32 • NO 2 • APRIL 2009 95 ■ TORAB et al ■ Following developments in the medical treatment of postoperative death, thus the mortality rate was 1/117 PUD in the last two decades, surgical intervention is cur- (0.9%). This patient had a diagnosis of perforated gastric rently confined to the treatment of complicated disease, cancer and was excluded from the statistics of the study as namely, ulcer haemorrhage, perforation and obstruction.8 the disease had different etiology and morbidity. Of the Simple closure or omental patch repair is the mainstay of other 116 patients, 114 were male (98.3%). The mean age of treatment of perforated peptic ulcer (PPU),9–11 definitive patients was 35.3 years (range, 20–65). No patient had surgery being rarely practised12 with dependence now chronic cardiac, pulmonary or hepatic dysfunction. Renal on medical therapy to complete the healing process and dysfunction was evident in two patients (1.7%), hypertension prevent recurrence of the disease.10,13–15 occurred in three (2.6%), and four had diabetes mellitus In this retrospective study we reviewed our PPU admis- (3.4%). None had significant organ dysfunction or failure. sions during a 4-year period to identify risk factors in this particular community, determine our morbidity and mor- Management tality rates and study factors affecting postoperative com- All patients were treated, first by resuscitation, then plications of PPU including Boey16 and APACHE II scores.17 open laparotomy, peritoneal toilet and closure of the per- foration employing an omental patch. Postoperatively, Patients and methods intravenous antibiotics were used for 3–5 days. One hundred and thirteen patients (97.4%) received postop- This is a retrospective study of the medical records of all erative oral eradication therapy with Amoxicillin 1 g twice adult patients admitted to the Department of Surgery at daily, Clarithromycin 500 mg twice daily for 1–2 weeks Al-Ain Hospital with the diagnosis of a perforated peptic plus Omeprazole (Losec) 20 mg twice daily for 10 days. ulcer which was confirmed intraoperatively during the period from 1 January 2000 to 31 March 2004. After Intraoperative findings defining our objectives and reviewing the literature, we Ulceration in the duodenal bulb was found in 107 of 116 designed a documentation sheet to collect data necessary patients (92.2%) there being only one ulcer in the second to complete the study. We obtained the approval of the part of the duodenum, six prepyloric ulcers and two gas- Research Ethics Committee and the Head of the tric ulcers. The patient who died had a perforation in an Department of Surgery and the Medical Records section adenocarcinoma; the only case of malignant ulceration in to undertake the study. The data were collected from the study and this patient was excluded from our analy- patients’ charts anonymously and documented. sis. Ulcer size was only documented in 109 patients; in seven patients it was not recorded. The mean diameter Inclusion criteria was 5.2 mm (range, 1–20). All patients > 18 years of age admitted during the period of the study with operatively confirmed PPU. Postoperative course The range of postoperative hospital stay was 3–26 days, Exclusion criteria the mean ± SD being 7.6 ± 3 days. The patient who stayed Patients with (a) association of bleeding and perforation, 26 days developed postoperative pleural effusion, pneu- (b) immunodeficiency arising from any cause apart from monia, liver abscess, and sepsis. He was treated by percu- diabetes mellitus, (c) vital data missing from the medical taneous drainage of the effusion and the abscess in records or (d) pregnancy. addition to antibiotic therapy. The patient who stayed only 3 days left at his own request and against advice as Patients he planned to travel to his home country. Demographic data One hundred and nineteen patients had been treated, two Postoperative morbidity of whom were excluded; in one case a lost medical record Postoperative complications including organ dysfunction could not be retrieved despite every effort being made and or failure were defined according to the published in the other, operative notes were missing from the definitions of Deithch et al.18 Twenty patients (17.2%) patient’s file. In the remaining 117 patients there was one developed postoperative complications. The most 96 ASIAN JOURNAL OF SURGERY VOL 32 • NO 2 • APRIL 2009 ■ PERFORATED PEPTIC ULCER ■ common were respiratory complications, which occurred regression model was used to define factors related to in 12 patients (10.3%). Cardiac complications occurred in postoperative complications.19,20 The outcome variable of two patients (1.7%), intra-abdominal infection including the logistic model was whether the patient had postoper- pelvic and right iliac fossa collections, and liver abscess ative complications or not and the factors which were occurred in three patients (2.5%). Wound infection was entered into the logistic model as covariates were factors diagnosed in two patients (1.7%). Seven patients (6%) that had a p value of less than 0.05 in the univariate analy- experienced other complications. Morbidity encountered sis. Different direct logistic models have been tried and in these patients included paralytic ileus (two), uremia explored until the best model was found and presented. with convulsions (one), confusion with hallucination (one), Data were analyzed using the Statistical Package for the diarrhea (one), and a hypotensive episode with dehydration Social Sciences (version 15, SPSS Inc., Chicago, IL, USA). (one). One patient had a postoperative “acute abdomen” For all analyses, a p value < 0.05 was considered significant. and was found to have gangrenous small bowel possibly due to hypotension with non occlusion of mesenteric ves- Results sels on Angio computed tomography (CT). He underwent small bowel resection and right hemicolectomy. Fifteen Risk factors related to the incidence of the disease patients each had a single complication, four patients Seasonal distribution of admissions each had two complications and one patient had three The number of patients with PPU admitted during the complications. winter months of November to February was four cases per month. This was higher than the rate of 1.34 cases per Follow up endoscopy month in non winter months (Table 1). The number of The plan of the study, and according to the policy of the patients admitted during the fasting month of Ramadan hospital, was to follow up all patients with PPU with (27 patients) (Table 2) was significantly higher than the endoscopy, to exclude a persistent peptic ulcers. Patient demographics are explained by the fact that most of our Table 1. Frequency of admissions per month patients are heavy manual workers on camp sites or con- Month of Total number Rate of admission struction sites based out of town, who may leave the coun- admission of admissions per month try after having an operation. Only 25 patients came for follow up endoscopy (21.6%). The remaining patients January* 16 3.2 failed to attend (78.4%).