By Author
  By Title
  By Keywords

November 1990, Volume 40, Issue 11

Original Article

PERFORATED DUODENAL ULCER - A LONG TERM FOLLOW-UP

Waquaruddin Ahmed  ( PMRC Research Centre, Jinnah Postgraduate Medical Centre, Karachi-35. )
Huma Qureshi  ( PMRC Research Centre, Jinnah Postgraduate Medical Centre, Karachi-35. )
Syed Ejaz Alarn  ( PMRC Research Centre, Jinnah Postgraduate Medical Centre, Karachi-35. )
Sarwar Jehan Zuberi  ( PMRC Research Centre, Jinnah Postgraduate Medical Centre, Karachi-35. )

ABSTRACT

Retrospective analysis of 115 cases of perforated duodenal ulcer was done to determine the long term prognosis of patients managed by suture plication. Male to female ratio was 7.8:1. Males were younger than females with a median age of 35 and 50 years respectively. Highest frequency was noted in the 4th decade. Thirty-eight percent cases were smokers and 8.7% were pan/tobacco chewers. Blood group 0 was predominant (36.5%). Ninety-five percent perforations were in the anterior wall of the Cap and 5% prepyloric. Of the 48 (42%) cases followed, 28 (58%) relapsed during a 15 year follow-up. The cumulative relapse rate increased with the increase of follow-up period. Patients who relapsed had a longer duration of symptoms prior to perforation (P < 0.05) than those who did not relapse (JPMA 40: 258, 1990).

INTRODUCTION

Simple closure of perforated duodenal ulcer was first introduced in 18801 and improvements in the surgical techniques and type of surgery (definitive vs suture plica­tion) have since been tried with variable results2-6. Al­though simple closure is the safest and easiest method of repair but long term followup of these patients show an ulcer relapse in about 34-76% of the patients. Definitive surgery like vagotomy and pyloroplasty although minimises the chances of a second surgery later but has its own contraindications such as contaminated peritoneal cavity, prolonged period of delay prior to surgery, age and associated systemic diseases. Most of the centres in Pakistan are performing simple closure of the perforation but as these patients are not followed up, little is known about the reperforation rates, recurrence of symptoms/ulcer and subsequent surgery. This retrospective study was, therefore, undertaken to see if any of the above questions could be answered and to further plan the strategy for future surgery.

PATIENTS AND METHODS

Case records of 115 patients of perforated duodenal ulcer were reviewed. Of these 60 patients were referred to the PMRC Research Centre by their treating surgeons/ physicians for evaluation/follow-up of their symptoms after surgery, while 55 patients were discharged straightaway from the surgical department and no follow-up was avail­able on them. Patients with inconclusive/incomplete records were excluded from the study. During follow-up, G.I. endoscopy was performed at 1-5 years intervals irrespective of the symptoms while urgent endoscopy was done in all those who developed upper G.I. symptoms during follow-up. Statistical analysis of the data was done using X2 and student\'s \'t\' test.

RESULTS

Of 115 cases of perforated duodenal ulcer, 102 were males and 13 females, giving a ratio of 7.8:1. Age of the patients ranged from 12-85 years with a median of 35 in males and 50 years in females. Highest frequency of perforation was found in the fourth decade. Forty four (38%) cases were smokers and 10 (8.7%) were taking pan with tobacco. Intake of alcohol, heroin and charas was present in one case each. Blood group was known in 52 cases, of these 19(36.5%) had blood group 0, 18(34.6%) B, 11(21.2%) A and 4(7.7%) AB. Past history of ulcer related symptoms was available in 100 cases, of these 68% were symptomatic and 32% had no symptom prior to perforation. Pain was the most frequent symptom in 58 (85%) followed by vomiting in 13 (19%), heart-burn and G.I. bleeding in 7 (10%) and flatulence in 2 (3%) patients. Most of the patients presented with sudden onset of pain, ranging from 1 hour to 12 days (mean 2±2 days). Site of perforation was known in 78 cases. Of these 74 (95%) were in the first part of the duodenum and 4(5%) were prepyloric. Seventy two (92%) cases had anterior wall perforation, one lesser curve and one both anterior and posterior wall perforations. Size of perforation varied from 1mm to 1cm with a mean of 3.5mm. In all cases simple closure and omentopexy was done. Total duration of hospital stay ranged from 5 to 45 days with a mean of 12±7.7 days. Follow-up was available in 48 cases which varied from 1 to 15 years. Cumulative relapse rate in those who turned up for follow-up showed that eleven patients (23%) relapsed within one year, 20(42%) in 5 years, 26(54%) in 10 years and 28(58%) in 15 years. Comparison of symptoms of patients who relapsed with those who did not relapse showed that the former group had significantly longer duration of symptoms (56±57 months) prior to surgery (P <0.05) than the later group (30± 24 months) (Table).

Other parameters like age, sex, smoking, tobacco chewing, size and site of ulcer showed no significant difference in the two groups.

DISCUSSION

Analysis of age and sex of perforated duodenal ulcer cases in the present study showed that perforation is occurring at a very young age in our country than that in the West7. This could be due to a larger number of younger individuals in our country as compared to the West. The median age of females was much higher (50 years) as compared to the males (35 years), suggesting the probable hormonal behaviour changes in females after menopause when they are equally at risk of developing diseases which are otherwise more frequent in males. The male to female ratio was also slightly higher in the present series 7.8:1 than that in the West and India8 (6.2:1). The reported relapse rate for duodenal ulcer after simple closure of perforation varied from 34 to 76%9,10. This is consistent with our finding of 58%. An interesting aspect of this follow-up study is an increase in the overall frequency of relapse with an increase in the duration of follow-up. It is similar to a report in which it was observed that the incidence of reoperations following simple closure increases, as the length of follow-up increases3. The present study showed that the patients who relapsed during follow-up, had a longer duration of symptoms prior to perforation (P <0.05) as compared to those who did not relapse (Table). This finding is similar to an earlier study7. Although simple closure is a time-honoured and life saving procedure for perforated duodenal ulcer but patients having longer duration of ulcer symptoms prior to perforation should be considered for definitive surgery if there are no other associated contraindications. This is a preliminary study involving retrospective analysis of a small number of cases. To further confirm our finding, a substan­tial number of cases should be studied prospectively.

REFERENCES

1. Mikulicz, J. Sur operativen behandlung des stenosirenden Magen­geschwurs. Verh. Deutsch. Ges. Chir., 1887; 16 : 337.
2. Mark, J.B. Factors influencing the treatment of perforated duodenal ulcer. Surg. Gynaecol. Obstet., 1969; 129 :325.
3. Nemanich, G.J. and Nicoloff, D.M. Perforated duodenal ulcer, long-term follow-up. Surgery, 1970; 67: 727.
4. Wangensteen, S.L., Wray, JtC., Golden, G.T. Perforated duodenal ulcer. Am. J. Surg., 1972; 123 : 538.
5. Griffin, G.E. and Organ, C.H. The natural history of the perforated duodenal ulcers treated by suture plication. Ann. Surg., 1976; 183:382.
6. Chen, B.W., Xie, P.Y., Jia, B.Q. and Cai, J. Acute perforated ulcers An analysis of 375 cases (Abstract). J. Gastrol. Hep., 1989; 4 (sup p13): 30.
7. Cassell, P. Perforated duodenal ulcer in reading from 1950-1959. Gut., 1969; 10 :454.
8. Khanna, A.K., Pandey, B. and Misra, M.K. Duodenalulcerperfora­tion — An etiological study (Abstract). Indian 3. Gastroenterol., 1989; 8 (Suppl. 4): 29.
9. Jirzik, H. Erfahrungen bei 327 freinen Magen-Zwolffingerdarm­Geschwurzperforationen. Arch. Klin. Chir., 1954; 277: 611.
10. Turner, F.P. Acute perforations of stomach, duodenum and jejunum. An analysis of 224 cases with late follow-up data on 147 cases of acute perforated peptic ulcer. Surg. Gynecol. Obstet., 1951;92:281.

Journal of the Pakistan Medical Association has agreed to receive and publish manuscripts in accordance with the principles of the following committees: