Satish, K (2010) Clinical study and management of perforated duodenal ulcer. Masters thesis, Madurai Medical College, Madurai.
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Abstract
INTRODUCTION: Duodenal ulcer is a very common disease in southern part of India. In the earlier years the main treatment of duodenal ulcer was primarily surgical, but now it’s out of vogue due to advent of effective medical line of treatment. However the important complication of duodenal ulcer which is perforation is still seen commonly and surgical intervention is considered the treatment of choice. Perforation of duodenal ulcer is one of the most serious and, life threatening complication of peptic ulcer. Perforation of duodenal ulcer leads to contamination of peritoneal cavity with duodenal and gastric secretions which may initiate catastrophic cascade of events which until stopped in its track can be detrimental to the life of the patient. Perforation can occur in a patient with past history of peptic ulcer but it is known occur in about 20% of patient without, any relevant preceding symptoms. It is estimated that roughly 1.3% of population above the age of 20 years have had some degree of peptic ulcer activity during any annual period. Duodenal perforation is one of the dreaded complications that is known to occur in 15% of all recognized duodenial ulcer cases. Thus perforation of duodenal ulcer has become a pestilence that threatens to cripple the economic and social life of significant section of society if un attended to. AIMS OF THE STUDY: The present study has been undertaken to evaluate the age and sex incidence and the importance of various mode of presentations. The predisposing factors along with the general condition of patient at presentation, which has a relationship with mortality and morbidity also has been considered. comparative study has been made between the types of treatment and complications associated with it also the time taken for surgery and post op. complications have been analyzed. The role of different types of operations performed and the mortality and morbidity associated with each type of surgery has been studied. Also the socio economic status dietary habits and blood group has been analyzed with respect to the presentation of DU perforation. OBJECTIVES: 1. To study the clinical aspects of perforated duodenal ulcer. 2. To study the results of different modes of treatment. 3. To compare mortality and morbidity of simple closure of perforation. MATERIALS AND METHODS: A prospective study consisting of 50 patients of DU perforation presenting as acute abdomen to casualty department of Government Rajaji Hospital, Madurai Medical college from September 2007 November 2009. The cases were collected at random and treated at various surgical units of Govt. Rajaji hospital. All the cases were admitted as emergencies. After admission a detailed history was taken and clinical evaluation was done and possible immediate investigations were done. All the 50 cases were taken up for emergency laparotomy. At laparotorny site of perforation. size of perforation and amount of peritoneal contamination was determined later by different operative techniques like simple closure of perforation with technical modification or pyeleroplasty or serosal patch were performed. The decision regarding the line of treatment and type of surgery to be performed in each case were arrived after consideration of following factors. 1. Age of patient, 2. General condition of patient, 3. Evidence of shock, 4. Clinical findings of distention, guarding, Rigidity were determined, 5. Plain X-ray abdomen in erect posture and DPL was undertaken to arrive at a clinical diagnosis. 6. Duration of Perforation, site of perforalion and size of perforation with the state of surrounding tissues was determined, 7. Associated medical illness was determined, 8. Amount of peritoneal contamination determined. CONCLUSION: The following list of conclusions drawn after study of 50 cases. DU perforation is one of the commonest acute abdominal emergencies between 2007 to 2009. Peak age incidence of 42 years shows that duodenal ulcer perforation has a predilection of young and middle age adults. Now-a-days, there is a increased incidence of DU perforation seen in aged indiciduals and these are the population at risk for morbidity and mortality. It is more common in low socioeconomic status, rural males. Majority did not have any previous history suggestive of chronic duodenal ulcer. In those present it varied from 1-2 years. Most patients presented with sudden onset of acute pain abdomen in epigastrium and presented to the hospital within 48 hours. General condition of the patient was stable at the time of admission in those patients who came within 48 hours and in those who were referred form other hospitals or general practitioners. All patients had generalized guarding, rigidity and diffuse tenderness with obliteration of liver dullness. All cases showed gas under diaphragm in one or both the domes of diaphragm with ground glass appearance. Diagnostic peritoneal tap was positive in all cases. It was bilious and in few cases pus was aspirated. Maximum number of cases were seen in blood group O. Most of the perforation cases underwent simple closure of perforation with technical modifications. A few cases underwent pyloroplasty due to edematous and friable surrounding tissues around the perforation site along with simple closure of perforation. Four cases had gaping at the site of skin over sutured wound, which was closed with the secondary suturing. Time of presentation – General condition of patient, size of perforation and time gap for surgery were all related to post operative complications. Increasing size of perforation with the type of closure performed had significant relationship with postoperative complications. There was one death, two were lost for follow up and one patient was discharged against medical advice. Simple diagnostic work up like plain x-ray abdomen-erect, chest and DPT with routine investigation of blood are quite sufficient in making a correct diagnosis and patients benefit from early presentation to the hospital. The operative treatment of simple closure’s perforation with technical modifications like closure of perforation with live pedicle of omentum or pedicel patch (patch graft) or omental plugging along with post operative PPIs or triple therapy is still the best method of treatment perforated duodenal ulcer. This is a cost effective method in our set up where majority of patients presenting are from poor, rural population in and around Madurai city. Clinical diagnosis is still the best method of arriving at a correct diagnosis of perforated duodenal ulcer and patients benefit from early presentation to the hospital.
| Item Type: | Thesis (Masters) |
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| Uncontrolled Keywords: | perforated duodenal ulcer, management, clinical study. |
| Subjects: | MEDICAL > General Surgery |
| Depositing User: | Devi S |
| Date Deposited: | 04 Jun 2018 17:47 |
| Last Modified: | 13 Jan 2020 12:21 |
| URI: | http://repository-tnmgrmu.ac.in/id/eprint/8181 |
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